Exploring the client's ability to function
Exploring the client's potential for self-harm
Inquiring about the client's perception or appraisal of the neighbor's death
Inquiring about and examining the client's feelings that may block adaptive coping
“What makes you think that I am a vampire?”
“I'll leave and come back later for your blood.”
“I am not going to hurt you; I am going to help you.”
“It must be frightening to think that others want to hurt you.”
“I don't see you as a failure.”
“You have everything to live for.”
“Feeling like this is all part of being ill.”
“You've been feeling like a failure for a while?”
“You're having difficulty sleeping?”
“Sometimes, I have trouble sleeping too.”
Using open-ended questions and silence
Focusing on self-disclosure regarding food preferences
Identifying the reasons that the client may not want to eat
Offering opinions about the necessity of adequate nutrition
“Have you shared your feelings with your family?”
“I think we should talk more about your anger with your family.”
“You're feeling angry that your family continues to hope for you to be cured?”
“Well, it sounds like you're being pretty pessimistic. After all, years ago, people died of pneumonia.”
The client will resist treatment measures.
The client will be angry and will refuse care.
The client's family will resist treatment measures.
The client will participate in the planning of the care and treatment plan
Contact the physician.
Call the client's family.
Persuade the client to stay a few more days.
Tell the client that discharge is not possible at this time.
Presents a harm to self
Requested the admission
Consented to the admission
Provided written application to the facility for admission
Planning short-term goals
Making appropriate referrals
Developing realistic solutions
Identifying expected outcomes
Needs to be admitted to the hospital.
Needs to be referred to the psychiatrist as soon as possible.
Requires further treatment and is not ready to be discharged.
Is displaying typical behaviors that can occur during termination.
“No, I won't tell anyone.”
“I cannot promise to keep a secret.”
“If you tell me the secret, I will tell it to your doctor.”
“If you tell me the secret, I will need to document it in your record.”
“I cannot discuss any client situation with you.”
“If you want to know about Carol, you need to ask her yourself.”
“I'm not suppose to discuss this, but because you are my neighbor, I can tell you that she is doing great!”
“I'm not suppose to discuss this, but because you are my neighbor, I can tell you that she really has some problems!”
“I need to continue with my visits. Your comment reflects a lack of knowledge that this disease runs in families.”
“I agree with you. Clients who want to kill themselves are only suicidal for a limited time. No one can feel self-destructive forever.”
“I agree with you. The suicidal threats were really attention seeking. Continuing to visit would reinforce your husband's use of manipulation.”
“I need to continue with my visits. Most suicides occur within 3 months after improvement begins because the client now has the energy to carry out the suicidal intentions.”
That the physician will provide the informed consent
That an informed consent does not need to be obtained
That an informed consent should be obtained from the family
That an informed consent needs to be obtained from the client
The nurse will be charged with assault.
The nurse will be charged with slander.
The nurse will be charged with imprisonment.
No charge will be made against the nurse because the nurse's actions are reasonable.
A form of behavior modification therapy
A cognitive approach to changing behavior
A living, learning, or working environment
A behavioral approach to changing behavior
“The leader is a nurse or psychiatrist.”
“The members provide support to each other.”
“People who have a similar problem are able to help others.”
“It is designed to serve people who have a common problem.”
Ask the client to leave.
Refer the client to another group.
Tell the client to stop monopolizing
Thank the client for the contribution and tell him or her to allow others a chance to contribute
Encourage accomplishment of the group's work.
Acknowledge the contributions of each group member.
Encourage members to become acquainted with one another.
Rational emotive therapy
Provide a supportive environment.
Examine intrapsychic conflicts and past issues.
Emphasize social interaction with clients who withdraw.
Help the client identify and examine dysfunctional thoughts and beliefs.
“This type of treatment will help you relax and develop new coping skills.”
“This type of treatment helps you confront your fears by gradually exposing you to them.”
“This type of treatment helps you examine how your past life has contributed to your problems.”
This type of treatment helps you examine how your thoughts and feelings contribute to your difficulties.”
Admitting to having a problem
Substituting other activities for gambling
Stating that the gambling will be stopped
Discontinuing relationships with friends who are gamblers
The group evaluates the experience.
The real work of the group is accomplished.
Group interaction involves superficial conversation.
Group members become acquainted with each other.
Some structuring of group norms, roles, and responsibilities take place.
The group explores members' feelings about the group and the impending separation.
Outlandish behaviors and inappropriate dress
Nonstop physical activity and poor nutritional intake
Grandiose delusions of being a royal descendent of King Arthur
Constant, incessant talking that includes sexual innuendoes and teasing the staff
“I don't believe this is true.”
“The guards are not out to kill you.”
“What makes you think the guards were sent to hurt you?”
“I don't know anything about the guards. Do you feel afraid that people are trying to hurt you?”
Remain with the client.
Put the client in a quiet room.
Teach the client deep breathing.
Encourage the client to talk about their feelings and concerns.
Move the client next to the nurse's station.
Use an indirect light source and turn off the television.
Keep the television and a soft light on during the night.
Play soft music during the night, and maintain a well-lit room.
Improvement in sleeping
Absence of sundown syndrome
Presence of personal hygienic care
“My medications won't make me anxious.”
“I'll go to support group and talk so that I don't hurt anyone.”
“I won't get anxious or hear things if I get enough sleep and eat well.”
“I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone.”
The client will function at the highest level of independence possible.
The client will complete all activities of daily living independently within a 1-hour time frame.
The client will be admitted to a long-term care facility to have activities of daily living needs met.
The nursing staff will attend to all the client's activities of daily living needs during the hospital stay.
Ask direct questions to encourage talking.
Leave the client alone and intermittently check on him.
Sit beside the client in silence with occasional open-ended questions.
Take the client into the dayroom with other clients so that they can help watch him.
Increase socialization of the client with peers.
Avoid laughing or whispering in front of the client.
Begin to educate the client about social supports in the community.
Have the client sign a release of information to appropriate parties so that adequate data can be obtained for assessment purposes.
Reading and writing most of the day
Several activities from which the client can choose
Nothing, until the client asks to participate in milieu
A structured program of activities in which the client can participate
Ignoring feelings of anxiety
Identifying anxiety-producing situations
Continued contact with a crisis counselor
Eliminating all anxiety from daily situations
Ask the client to leave the group session.
Ask another nurse to escort the client out of the group session.
Tell the client that she will not be able to attend any future group sessions.
Tell the client that she needs to allow other clients in the group time to talk.
Orient the client to time, person, and place.
Tell the client that the behavior is not appropriate.
Escort the manic client to her room, with assistance.
Tell the client that smoking privileges are revoked for 24 hours.
Weigh the client three times per week before breakfast.
Explain to the client the importance of a good nutritional intake.
Schedule brief nursing interactions with the client during several meals in which small portions are offered.
Report the nutritional concern to the psychiatrist and obtain a nutritional consultation as soon as possible.
Tell the client that this is not true, that we all have a purpose in life.
Identify recent behaviors or accomplishments that demonstrate the client's skills.
Reassure the client that you know how the client is feeling and that things will get better.
Remain with the client and sit in silence; this will encourage the client to verbalize feelings.
Disturbed thought processes.
Provide safety for the client and other clients on the unit.
Provide the clients on the unit with a sense of comfort and safety.
Assist the staff in caring for the client in a controlled environment.
Offer the client a less stimulated area to calm down and gain control.