A nurse on an inpatient mental health unit is assisting with a series of group therapy sessions for a small group of clients.
Nurses Notes
Session 1:
Client A states they are fearful at times.
Client B is sobbing and states they can't go a day without their partner.
Client C remains silent during the session.
Client D wears boots 24 hr per day.
Client E continuously twists their hair.
Session 4:
Client A admits to having an extreme fear of mice, among other things.
Client B brings a picture of their partner to the session and cries when looking at the photo.
Client C has yet to speak during a group session.
Client D tells the group they wear boots all the time because they have the world’s ugliest feet and don’t want anyone to see them.
Client E is now pulling out hair after they have twisted it
The nurse is reviewing the observations made from the various group sessions. Drag words from the choices below to fill in each blank in the following sentences.
1. Client A is exhibiting manifestations of ___Target 1
2. Client B is experiencing manifestations of ____Target 2
3. Client C continues to exhibit manifestations of ____Target 3
4. Client D is displaying manifestations of ___Target 4
5. Client E has worsening manifestations that have now progressed to ___Target 5
Word Choices
separation anxiety
trichotillomania
murophobia
Mutism
Body dysmorphism
The Correct Answer is C, A, D, E, B
Rationale:
Murophobia: Client A's extreme fear of mice indicates a specific phobia. In this case, it is specifically referred to as murophobia.
Separation anxiety: Client B's distress over their partner's absence aligns with separation anxiety.
Mutism: Client C's continued silence in group sessions suggests mutism, a form of non-verbal behavior often associated with anxiety or trauma.
Body dysmorphism: Client D's behavior of wearing boots due to negative feelings about their feet reflects body dysmorphic disorder, where a person has a distorted view of their body.
Trichotillomania: Client E’s behavior of pulling out their hair after twisting it indicates trichotillomania, a disorder characterized by compulsive hair pulling.
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View Related questions
Correct Answer is B
Explanation
Rationale:
A. Offering reassurance without addressing the client's immediate concerns may minimize the severity of the situation and delay necessary interventions.
B. Asking the client about the lethality of their plan is crucial for assessing the level of risk and determining the urgency of the intervention required. This information is essential for planning appropriate care and ensuring the client's safety.
C. Allowing the client to be alone is not appropriate when they have expressed suicidal intent, as this could increase the risk of self-harm.
D. Encouraging the client to focus on the positive aspects of life may be part of long-term therapy, but in the acute phase, the priority is to assess and address the immediate risk of suicide.
Correct Answer is B
Explanation
Rationale:
A. Placing a client with active tuberculosis in a room with another client increases the risk of airborne transmission of the infection, which is inappropriate for infection control.
B. A room with air exhaust directly to the outdoor environment is ideal for a client with active tuberculosis because it provides negative pressure, helping to contain and prevent the spread of the infectious airborne particles.
C. The ICU is typically reserved for critically ill patients requiring intensive monitoring and care, and it may not provide the necessary infection control measures for TB.
D. A room near the nurses' station would not ensure the negative pressure ventilation needed to prevent airborne transmission of tuberculosis.