Chapter 08: Principles and Skills of Mental Health Care Morrison-Valfre: Foundations of Mental Health Care, 7th Edition MULTIPLE CHOICE 1. An adult female client becomes combative with the nurse during routine medication administration. What is the nurse’s primary responsibility in this situation? a. To ensure that the client takes her medications b. To ensure that the client is placed in physical restraints to protect the safety of the staff and other clients c. To ensure that chemical restraints are used in the future until the client displays more appropriate and compliant behavior d. To ensure that the client is kept safe while trying to protect staff safety and to reason with the client to try to de-escalate the combative behavior ANS: D The “Do no harm” principle of mental health care applies to this situation. Client and staff safety are imperative. Ensuring that the client takes her medications is not of greatest concern in this situation because this most likely would cause increased combativeness. Physical restraints and chemical restraints are not reasonable options in the care of this patient. DIF: Cognitive Level: Application REF: p. 86 OBJ: 2 TOP: Do No Harm KEY: Nursing Process Step: Intervention MSC: Client Needs: Safe and Effective Care Environment 2. A nurse is trying to develop trust with a client on an inpatient mental health unit. Which action by the nurse is going to best promote development of a mutually trusting relationship? a. At the beginning of the shift, the nurse promises to play a game of cards with the client at some point during that day and does so before the end of the shift. b. The nurse promises to play a game of cards with the client on the following day. c. The nurse leads a group discussion with clients about ways to develop trust in a relationship. d. The nurse gives the client written information about the medications he is taking. ANS: A Developing mutual trust is one of the principles of mental health care. The nurse most likely would be able to carry out plans on a daily basis rather than trying to make plans for the next day. Making plans with the client is a very effective way to develop trust, as long as the plans can be carried out. Leading a group discussion and giving written information are helpful to clients but are not going to promote development of trust in the same way that making plans and carrying them out would do. DIF: Cognitive Level: Application REF: p. 82 OBJ: 3 TOP: Develop Mutual Trust KEY: Nursing Process Step: Intervention MSC: Client Needs: Psychosocial Integrity
NURSING TEST BANK
