Question 1 A 70-year-old client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day, he tries to get out of the locked unit several times. He yells, "I have to leave and get to my barber. I see him every Wednesday. Let me out!” The most therapeutic response by the nurse would be: Sele cted Answ er: "You need to come and take a shower before you can go get your hair cut." Answers:"You need to come and take a shower before you can go get your hair cut." "Please stop banging on the door. Your room is right over there. " "The door is locked so that you don’t leave and get hurt." "It's Monday and you’re in the hospital. I'm your nurse." Response Feedback : NUR2488 MENTAL HEALTH NURSING MH EXAM3 NUR 2488 EXAM Q & AS ALL 100% VERIFIED ANSWERS LATEST UPDATE 2022/2023 GRADED A+ RASMUSSEN COLLEGE, MINNEAPOLIS NUR2488 MENTAL HEALTH NURSING MH EXAM3 NUR 2488 EXAM Q & AS ALL 100% VERIFIED ANSWERS LATEST UPDATE 2022/2023 GRADED A+ RASMUSSEN COLLEGE, MINNEAPOLIS The best resp onse is to orie nt the client to the day, place and the people around him. Telling him to stop banging on the door and to go to his room is a non-therapeutic response. Explaining why the door is locked does not provide orientation and is irrelevant to his concern about needing to get to the barber. Promising that he can go to the barber after a shower does not present reality. • Question 2 Which intervention is most effective in managing excessive demands from a client with borderline personality disorder? Sele cted Answ er: Be consistent in responses to client demands. Answers:Assign two staff members per shift to this client. Hold a quick staff meeting whenever the client has a complaint NUR2488 MENTAL HEALTH NURSING MH EXAM3 NUR 2488 EXAM Q & AS ALL 100% VERIFIED ANSWERS LATEST UPDATE 2022/2023 GRADED A+ RASMUSSEN COLLEGE, MINNEAPOLIS NUR2488 MENTAL HEALTH NURSING MH EXAM3 NUR 2488 EXAM Q & AS ALL 100% VERIFIED ANSWERS LATEST UPDATE 2022/2023 GRADED A+ RASMUSSEN COLLEGE, MINNEAPOLIS Be consistent in responses to client demands. Be flexible and willing to change your mind Resp onse Feed back : Because people with borderline personality disorder have emotional lability and inconsistency in behavior, it’s important for the nurse to be consistent in responses and limits. The person with borderline personality will often test boundaries and rules; being consistent and not changing one’s mind frequently will help the individual feel safe in the environment. Assigning two people per shift can contribute to the tendency to pit two people against each other in order to create conflict. Holding a quick staff meeting in response to client complaints does not keep firm boundaries and allows staff to be manipulated. • Question 3 A client is admitted for acute alcohol withdrawal. Which of the following clinical manifestations indicate the need for treatment of acute alcohol withdrawal? Selected Answer: NUR2488 MENTAL HEALTH NURSING MH EXAM3 NUR 2488 EXAM Q & AS ALL 100% VERIFIED ANSWERS LATEST UPDATE 2022/2023 GRADED A+ RASMUSSEN COLLEGE, MINNEAPOLIS NUR2488 MENTAL HEALTH NURSING MH EXAM3 NUR 2488 EXAM Q & AS ALL 100% VERIFIED ANSWERS LATEST UPDATE 2022/2023 GRADED A+ RASMUSSEN COLLEGE, MINNEAPOLIS T a chycardia, paranoid delusions, and elevated blood pressure Answers: Myopia, hypothermia, and elevated mood. Bradycardia, hypotension and drowsiness. Decreased reflexes, somnolence and hypothermia. Tachycardia, paranoid delusions, and elevated blood pressure Respo nse Feedb ack: Tachycardia, delusions, hallucinations, and elevated blood pressure are symptoms of alcohol withdrawal. • Question 4 A client with vascular dementia is experiencing agnosia. She sits at her dining table looking at her food, but doesn’t pick up a utensil and try to eat. Which intervention is most appropriate for the nurse to try first? Selected Answer: