NURS (413)
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Q1           Score:  1
 Disturbed sleep patterns R/T agitation.
 Risk for violence: self-directed R/T depressive symptoms.
 Altered thought processes R/T biochemical alterations.
 Social isolation R/T grandiosity.
Q2           Score:  1
 "Thank you. I think you are special too."
 "I suspect you want something from me. What is it?"
 "You probably say that to all your nurses."
 "Are you thinking of suicide?"
Q3           Score:  1
 Complete a thorough physical assessment including lab tests.
 Remove all hazardous materials from the environment.
 Request a psychiatric consultation.
 Place the client on a one-to-one observation.
Q4           Score:  1
 Promote attendance in group therapy to assist client to socialize.
 Focus on strengths and accomplishments to minimize failures.
 Encourage the client to journal to uncover underlying feelings.
 Teach assertiveness skills by role-playing situations.
Q5           Score:  1
 Cheerful but not too stimulating
 Active and stimulating
 Active, interesting, and exciting
 Very permissive and stress- free
Q6           Score:  1
 Right to freedom
 Right to refuse treatment
 Right to sign legal documents
 The client loses no rights
Q7           Score:  1
 Stress
 Self-regulation
 Homeostasis
 Fight-or-flight response
Q8           Score:  1
 Rationalization.
 Repression.
 Undoing.
 Suppression.
Q9           Score:  1
 Sublimation
 Displacement
 Isolation
 Conversion
Q10           Score:  1
 Repression
 Rationalization
 Undoing
 Conversion
Q11           Score:  1
 Grandiosity.
 Flight of ideas.
 Catatonic state.
 Pressure of speech.
Q12           Score:  1
 Crying when discussing sadness.
 An abrupt improvement in mood.
 Statements such as "Everything will be better soon."
 Feeling overwhelmed by simple daily tasks.
Q13           Score:  1
 Feeling unworthy of food.
 Being preoccupied with trivialities.
 Thinking the food is poisoned.
 Not slowing down long enough to eat.
Q14           Score:  1
 Irritable mood
 Labile affect
 Apathy
 Euphoria
Q15           Score:  1
 Threat is not a delusion
 History of violence
 Potential victim(s) are identifiable
 Potential victim is easy to locate
Q16           Score:  1
 Maintain self-esteem
 Handle pain
 Carry out medical treatment
 Confront family problems
Q17           Score:  1
 Displacement.
 Isolation.
 Compensation.
 Regression.
Q18           Score:  1
 Have little contact with the client to decrease stimulation.
 Provide the client with privacy to maintain confidentiality.
 Maintain contact with the client and assure the client that seclusion is a way to maintain the client’s safety.
 Teach the client relaxation techniques and effective coping strategies to deal with anger.
Q19           Score:  1
 Correct and remind the student of the importance of maintaining client confidentiality.
 Tell the student that because the client has been deemed incompetent, confidentiality is not an issue.
 Reinforce the importance of accurate documentation, including the client’s name.
 Tell the student that because the client is involuntarily committed, confidentiality is not an issue.
Q20           Score:  1
 A client with delusions states, “I’m going to get them before they get me.”
 A hostile client says, “I hate all police.”
 A client says he plans to blow up the federal government.
 A client states, “If I can’t have my girlfriend back, then no one can have her.”


   



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