Tiêu đề KEY - R12 NP5.docx ✅

4. Vanya used manipulation to get her needs met. The staff decides to apply limit-setting interventions. What is the correct rationale for this action? A. It provides an outlet for feelings of anger and frustration. B. It respects the patient's wishes so assertiveness will develop. C. External controls are necessary while internal controls are developed. D. Anxiety is reduced when staff members assume responsibility for the patient's behavior. Answer: C Rationale: The nurse must provide structure in the therapeutic relationship, identify acceptable and expected behaviors, and be consistent in those expectations. He or she must minimize attempts by these clients to manipulate and control the relationship. Limit setting is an effective technique that involves three steps: 1. Stating the behavioral limit (describing the unacceptable behavior) 2. Identifying the consequences if the limit is exceeded 3. Identifying the expected or desired behavior For clients who feel out of control, the nurse must establish external controls empathetically and non- judgmentally. These external controls provide long-term comfort to clients, though their initial response may be aggression. All staff must consistently set and enforce limits for those limits to be effective. Limits must be established by others when the client is unable to use internal controls effectively. Source: Videbeck, S. (2020). Psychiatric-Mental Health Nursing. 8th edition p. 710, 765 5. Given the behavior of Vanya or Xylo, limit setting be most essential if either of them ___________________________. A. Clings to the nurse and asks for advice about inconsequential matters. B. Flirts with and is provocative with staff members of the opposite sex. C. Displays hypervigilant behavior and refuses to attend unit activities. D. Urges a suspicious patient to hit anyone who stares. Answer: B Rationale: Erratic patterns of thinking and behaving often alienate them from others. This may be true for both professional and personal relationships. Clients can easily misinterpret the nurse’s genuine interest and caring as a personal friendship, and the nurse may feel flattered by a client’s compliments. The nurse must be quite clear about establishing the boundaries of the therapeutic relationship to ensure that neither the client’s nor the nurse’s boundaries are violated. Source: Videbeck, S. (2020). Psychiatric-Mental Health Nursing. 8th edition p. 783 Situation: Greta, 54-years old and a known hypertensive (controlled), was seen in her ophthalmologist's office for a routine eye examination. Her last examination was five (5) years ago. Reports of significant visual field loss was determined to be caused by wide-angle glaucoma. Nurse Jenny was tasked to assist the patient in her care. 6. Laser trabeculoplasty as a form of treatment was suggested to Greta. Which of the following nursing measures should receive priority in the client's plan of care after eye surgery? A. Prevent increase in intraocular pressure (IOP) and signs of infection B. Instruct on the importance of follow-up C. Instruct on how to perform the Valsalva maneuver D. Management of pain through patient-controlled analgesia (PCA) Answer: A Rationale: The primary focus of treatment is to keep the IOP low enough to prevent the patient from developing optic nerve damage. After eye surgery, include the following information in the teaching plan for the patient and caregiver: ● Proper hygiene and eye care techniques to ensure that dressings and/or surgical wound is not contaminated during eye care ● Signs and symptoms of infection (e.g., increased or purulent drainage, increased redness, any decrease in visual acuity) and when and how to report these to allow for early recognition and treatment of possible infection ● Importance of following restrictions on head positioning, bending, coughing, and Valsalva maneuver to optimize visual outcomes and prevent increased IOP ● How to instill eye medications using aseptic technique and adherence with prescribed eye medication routine to prevent infection