On review of the client’s record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?

Anger and aggressiveness directed toward others

Fearfulness regarding treatment measures

Willingness to participate in the planning of the care and treatment plan

An understanding of the pathology and symptoms of the diagnosis

Answer and Explanation

The Correct Answer is C

Choice A reason:
Anger and aggressiveness directed toward others are not typically associated with voluntary admission. Clients who voluntarily seek treatment are usually motivated to improve their condition and are less likely to exhibit aggressive behaviors towards others. Aggressiveness may be more common in involuntary admissions where the client feels coerced.

Choice B reason:
Fearfulness regarding treatment measures can occur in any client, regardless of whether the admission is voluntary or involuntary. However, clients who voluntarily admit themselves are generally more open to treatment and less likely to exhibit significant fearfulness about the treatment process.

Choice C reason:
Willingness to participate in the planning of the care and treatment plan is a common behavior in clients who have voluntarily admitted themselves. These clients are typically motivated to engage in their treatment and collaborate with healthcare providers to achieve their health goals. Voluntary admission often indicates a proactive approach to managing their condition.

Choice D reason:
An understanding of the pathology and symptoms of the diagnosis is not necessarily linked to the nature of the admission. While some clients may have a good understanding of their condition, others may not, regardless of whether their admission was voluntary or involuntary. Education about the diagnosis is an important part of the treatment process for all clients.

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Correct Answer is A

Explanation

Choice A reason:

“It is now time for you to bathe. Do you want to wear the red or green shirt?” This statement is therapeutic as it provides clear instructions and offers the client a choice, promoting autonomy and cooperation. It addresses the need for hygiene in a respectful and supportive manner.

Choice B reason:

“Do you really think it is okay not to bathe? What is going on with you?” This statement is confrontational and judgmental. It may make the client feel defensive or ashamed, which can hinder the therapeutic relationship and the client’s willingness to engage in self-care.

Choice C reason:

“This is it! You are getting a bath! There are three of us here to bathe you!” This statement is coercive and does not respect the client’s autonomy. Forcing the client to bathe without their consent can escalate the situation and damage trust between the client and the nurse.

Choice D reason:

“I’m going to ignore your lack of self-care because it is an aspect of the disorder.” Ignoring the client’s hygiene issues is not therapeutic. While it is important to understand that self-care deficits can be part of the disorder, the nurse should still address these issues in a supportive and respectful manner.

A. Develop a flexible crisis intervention plan. B. Identify the cause of the anxiety. C. Validate the client’s feelings. D. Establish rapport with the client. E. Avoid eye contact to prevent escalation of anxiety.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason:

Developing a flexible crisis intervention plan is essential in managing a client’s anxiety crisis. Flexibility allows the nurse to adapt the plan to the client’s changing needs and circumstances, ensuring that the interventions remain effective and appropriate.

Choice B reason:

Identifying the cause of the anxiety is crucial for effective intervention. Understanding the underlying factors contributing to the client’s anxiety helps the nurse address the root of the problem and develop targeted strategies to alleviate the client’s distress.

Choice C reason:

Validating the client’s feelings is an important therapeutic technique. It helps the client feel understood and supported, which can reduce anxiety and build trust between the client and the nurse. Validation acknowledges the client’s emotions without judgment.

Choice D reason:

Establishing rapport with the client is fundamental in any therapeutic relationship. Building rapport fosters trust and open communication, which are essential for effective crisis intervention. A strong therapeutic relationship can help the client feel more secure and supported.

Choice E reason:

Avoiding eye contact is not recommended as it can be perceived as dismissive or disinterested. Maintaining appropriate eye contact shows that the nurse is engaged and attentive, which can help reassure the client and reduce anxiety. It is important to balance eye contact to avoid making the client feel uncomfortable.

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On review of the client’s record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been diagnosed with schizophrenia. The client has been wearing the same clothes for the past week and appears unkempt and unbathed. Which of the following statements should the nurse make to the client?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? (Select all that apply).

Correct Answer is ["A","B","C","D"]

Explanation

A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

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)

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?

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions?

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?

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?

When providing care to a client diagnosed with a mental disorder, the client asks the nurse, “Does mental illness run in your family?” Which response by the nurse would be nontherapeutic?