All Nurse Lab

In clients with a cognitive impairment disorder, the phenomenon of increased confusion in the early evening hours is called:

Sundowning

A client tells a nurse. "Everyone would be better off if I wasn't alive." Which nursing diagnosis would be made based on this statement?

Risk for self-directed violence

A client was admitted to the psychiatric unit for severe depression. After several days, the client continues to withdraw from other clients. Which of the following would be the MOST appropriate statement by the nurse to promote interaction with other clients?

"Come play Chinese Checkers with Gerry and me."

Which of the following is one of the advantages of the newer antipsychotic medication risperidone (Risperdal)?

A lower incidence of extrapyramidal effects

Which of the following medications would the nurse expect the physician to order to reverse a dystonic reaction? A. prochlorperazine (Compazine) B. diphenhydramine (Benadryl) C. haloperidol (Haldol) D. midazolam (Versed)

B. diphenhydramine (Benadryl)

A male client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor's dog on fire. When evaluating this client for the potential for violence, nurse Perry should assess for which behavioral clues?

A rigid posture, restlessness, and glaring

Mental health is defined as:

A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively.

Lorraine has been diagnosed with somatic symptom disorder. Which of the following symptom profiles would you expect when assessing Lorraine?A) multiple somatic symptoms in several body systemsB) fear of having a serious diseaseC) loss or alteration in sensorimotor functioningD) belief that her body is deformed or defective in some way

A) multiple somatic symptoms in several body systems

32. When taking a health history from a female client who has a moderate level of cognitive impairment due to dementia, the nurse would expect to note the presence of: A. Accentuated premorbid traits B. Enhance intelligence C. Increased inhibitions D. Hyper vigilance

A. A moderate level of cognitive impairment due to dementia is characterized by increasing dependence on environment & social structure and by increasing psychologic rigidity with accentuated previous traits & behaviors.

33. A male client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor's dog on fire. When evaluating this client for the potential for violence, nurse Perry should assess for which behavioral clues? A. A rigid posture, restlessness, and glaring B. Depression and physical withdrawal C. Silence and noncompliance D. Hypervigilance and talk of past violent acts

A. A rigid posture, restlessness, and glaring Behavioral clues that suggest the potential for violence includes: a rigid posture, restlessness, glaring, a change in usual behavior, clenched hands, overtly aggressive actions, physical withdrawal, noncompliance, overreaction, hostile threats, recent alcohol ingestion or drug use, talk of past violent acts, inability to express feelings, repetitive demands and complaints, argumentativeness, profanity, disorientation, inability to focus attention, hallucinations or delusions, paranoid ideas or suspicions, and somatic complaints.

47. Kevin is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with: A. Antisocial personality disorder B. Borderline personality disorder C. Obsessive-compulsive personality disorder D. Narcissistic personality disorder

A. Antisocial personality disorder The client's history of delinquency, running away from home, vandalism, and dropping out of school are characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others.

48. A client with major depression has not verbalized problem areas to staff or peers since admission to a psychiatric unit. Which activity should the nurse recommend to help this client express himself? A. Art therapy in a small group B. Basketball game with peers on the unit C. Reading a self-help book on depression D. Watching movie with the peer group

A. Art therapy provides a nonthreatening vehicle for the expression of feelings, and use of a small group will help the client become comfortable with peers in a group setting. Basketball is a competitive game that requires energy; the client with major depression is not likely to participate in this activity. Recommending that the client read a self-help book may increase, not decrease his isolation. Watching movie with a peer group does not guarantee that interaction will occur; therefore, the client may remain isolated.

A client with catatonic schizophrenia is mute, can't perform activities of daily living, and stares out the window for hours. What is the nurse's first priority? A. Assist the client with feeding. B. Assist the client with showering C. Reassure the client about safety D. Encourage socialization with peers

A. Assist the client with feeding

2. Nurse John is aware that a serious effect of inhaling cocaine is? A. Deterioration of nasal septum B. Acute fluid and electrolyte imbalances C. Extra pyramidal tract symptoms D. Esophageal varices

A. Cocaine is a chemical that when inhaled, causes destruction of the mucous membranes of the nose.

35. The nurse understands that the therapeutic effects of typical antipsychotic medications are associated with which neurotransmitter change? A. Decreased dopamine level B. Increased acetylcholine level C. Stabilization of serotonin D. Stimulation of GABA

A. Excess dopamine is thought to be the chemical cause for psychotic thinking. The typical antipsychotics act to block dopamine receptors and therefore decrease the amount of neurotransmitter at the synapses. The typical antipsychotics do not increase acetylcholine, stabilize serotonin, stimulate GABA.

A Schizophrenic client states, "I hear the voice of King Tut." Which response by the nurse would be the most therapeutic? A. I don't hear the voice, but i know you hear what sounds like a voice. B. You shouldn't focus on that voice C. Don't worry about the voices as it doesn't belong to anyone real D. Kind Tut has been dead for years

A. I don't hear the voice, but i know you hear what sounds like a voice.

Which of the following groups of characteristics would the nurse expect to see in the client with schizophrenia? A. Loose association, grandiose delusions, and auditory hallucinations B. Periods of hyperactivity and irritability alternating with depression C. Delusions of jealousy and persecution, paranoia, and mistrust D. Sadness, apathy, feelings of worthlessness, anorexia, and weight loss

A. Loose association, grandiose delusions, and auditory hallucinations

16. PROPRANOLOL (Inderal) is used in the mental health setting to manage which of the following conditions? A. Antipsychotic - induced akathisia and anxiety B. Obsessive - compulsive disorder (OCD) to reduce ritualistic behavior C. Delusions for clients suffering from schizophrenia D. The manic phase of bipolar illness as a mood stabilizer

A. Propranolol is a potent beta adrenergic blocker and producing a sedating effect, therefore it is used to treat antipsychotic induced akathisia and anxiety.

The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority? A. Risk for violence toward self or others B. Imbalanced nutrition: Less than body requirements C. Ineffective family coping D. Impaired verbal communication

A. Risk for violence toward self or others

1. Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam (Serax). Before administering the medication, nurse Gina should be prepared for which common adverse effect? A. Seizures B. Shivering C. Anxiety D. Chest pain

A. Seizures Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose.

42. Jose who has been hospitalized with schizophrenia tells Nurse Ron, "My heart has stopped and my veins have turned to glass!" Nurse Ron is aware that this is an example of: A. Somatic delusions B. Depersonalization C. Hypochondriasis D. Echolalia

A. Somatic delusion is a fixed false belief about one's body.

A client is admitted to a psychiatric facility with a diagnosis of chronic schizophrenia. The history indicates that the client has been taking neuroleptic medication for many years. Assessment reveals unusual movement of the tongue, neck, and arms. Which condition should the nurse suspect? A. Tardive dyskinesia B. Dystonia C. Neuroleptic malignant syndrome D. Akathisia

A. Tardive dyskinesia

8. For a female client with anorexia nervosa, Nurse Jimmy is aware that which goal takes the highest priority? A. The client will establish adequate daily nutritional intake B. The client will make a contract with the nurse that sets a target weight C. The client will identify self-perceptions about body size as unrealistic D. The client will verbalize the possible physiological consequences of self-starvation

A. The client will establish adequate daily nutritional intake According to Maslow's hierarchy of needs, all humans need to meet basic physiological needs first. Because a client with anorexia nervosa eats little or nothing, the nurse must first plan to help the client meet this basic, immediate physiological need.

27. Nursing preparation for a client undergoing electroconvulsive therapy (ECT) resemble those used for: A. General anesthesia B. Cardiac stress testing C. Neurologic examination D. Physical therapy

A. The nurse should prepare a client for ECT in a manner similar to that for general anesthesia.

During the initial interview, a client with schizophrenia suddenly turns to the empty chair besides him and whispers, "Now just leave. I told you to stay home. There isn't enough work here for both of us!" What is the nurse's best initial response? A. When people are under stress, they may see things or hear things that others don't. Is that what just happened? B. I'm having a difficult time hearing you. Please look at me when you talk. C. There is no one else in the room. What are you doing? D. Who are you talking to? Are you hallucinating?

A. When people are under stress, they may see things or hear things that others don't. Is that what just happened?

The nurse must administer a medication to reverse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. The medication the client will likely receive is: A. Benzotropine (Cogentin) B. diphenhydramine (Benadryl) C. propranolol (Inderal) D. haloperidol (Haldol)

A. benzotripine (Cogentin)

A man is brought to the hospital by his wife, who states for the past week her husband has refused all meals and accused her of trying to poison him. During the initial interview, the client's speech, only partly comprehensive, reveals his thoughts are controlled by delusions that he is possessed by the devil. The physician diagnoses paranoid schizophrenia. Schizophrenia is best described as a disorder characterized by: A. disturbed relationship related to inability to communicate or think clearly. B. severe mood swings and periods of low to high activity C. multiple personalities, one of which is more destructive than the others D. auditory and tactile hallucinations

A. disturbed relationship related to inability to communicate or think clearly.

The nurse knows that the physician has ordered the liquid form of the drug chlorpromazine (Thorazine) rather than the tablet form because the liquid: A. has a more predictable onset of action B. produces fewer anticholinergic effects C. produces fewer drug interactions D. has a longer duration of action

A. has a more predictable onset of action

A client with paranoid-type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should: A. tell him she'll leave for now, but will return soon B. ask him if it's okay if she sits quietly with him C. ask him why he wants to be left alone D. tell him that she won't let anything happen to him

A. tell him she'll leave for now, but will return soon

Which neurotransmitter has been implicated in the development of Alzheimer's disease?

Acetylcholine

When planning the therapeutic milieu, it is MOST important to select group activities which

Achieve clients' therapeutic goals

David is preoccupied with numerous bodily complaints even after a careful diagnostic workup reveals no physiologic problems. Which nursing intervention would be therapeutic for him?

Acknowledge that the complaints are real to the client, and refocus the client on other concerns and problems.

32. Discharge instructions for a male client receiving tricyclic antidepressants include which of the following information? A. Restrict fluids and sodium intake B. Don't consume alcohol C. Discontinue if dry mouth and blurred vision occur D. Restrict fluid and sodium intake

B. Drinking alcohol can potentiate the sedating action of tricyclic antidepressants. Dry mouth and blurred vision are normal adverse effects of tricyclic antidepressants.

A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty swallowing. The nurse's first action is to: A. Reassure the client and administer as needed lorazepam (Ativan) IM B. Administer as needed dose of benzotropine (Cogentin) IM as needed C. Administer as needed dose of benzotropine (Cogentin) PO as ordered C. Administer as needed dose of haloperidol (Haldol) PO

B. Administer as needed dose of benzotropine (Cogentin) IM as needed

A person with antisocial personality disorder has toughness relating to others because of never having learned to: A. Count on others B. Empathize with others C. Be dependent on others D. Communicate with others socially

B. Empathize with others

The nurse formulates a nursing diagnosis of impaired social interaction related to disorganized thinking for a client with schizotypical personality disorder. Based on this nursing diagnosis, which nursing intervention takes highest priority? A. Helping the client to participate in social interactions B. Establishing a one-on-one relationship with the client C. Exploring the effects of the client's behavior on social interactions D. Developing a schedule for the clients participation in social interactions

B. Establishing a one-on-one relationship with the client

49. A client whose husband just left her has a recurrence of anorexia nervosa. Nurse Vic caring for her realizes that this exacerbation of anorexia nervosa results from the client's effort to: A. Manipulate her husband B. Gain control of one part of her life C. Commit suicide D. Live up to her mother's expectations

B. Gain control of one part of her life By refusing to eat, a client with anorexia nervosa is unconsciously attempting to gain control over the only part of her life she feels she can control.

A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate? A. I think you're wrong. France is a friendly country and an ally of the United States. Their government wouldn't try to kill you B. I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this. C. You're wrong. Nobody is trying to kill you. D. A foreign government is trying to kill you? Please tell me more about it.

B. I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this.

41. Nurse Amy is aware that the client is at highest risk for suicide? A. One who appears depressed frequently thinks of dying and gives away all personal possessions B. One who plans a violent death and has the means readily available C. One who tells others that he or she might do something if life doesn't get better soon D. One who talks about wanting to die

B. One who plans a violent death and has the means readily available The client at highest risk for suicide is one who plans a violent death (for example, by gunshot, jumping off a bridge, or hanging), has a specific plan (for example, after the spouse leaves for work), and has the means readily available (for example, a rifle hidden in the garage).

19. Kris periodically has acute panic attacks. These attacks are unpredictable and have no apparent association with a specific object or situation. During an acute panic attack, Kris may experience: A. Heightened concentration B. Decreased perceptual field C. Decreased cardiac rate D. Decreased respiratory rate

B. Panic is the most severe level of anxiety. During panic attack, the client experiences a decrease in the perceptual field, becoming more focused on self, less aware of surroundings and unable to process information from the environment. The decreased perceptual field contributes to impaired attention andinability to concentrate.

A client is admitted with a diagnosis of schizotypical personality disorder. Which signs would this client exhibit during social situations? A. Aggressive behaviors B. Paranoid thoughts C. Emotional affect D. Independence needs

B. Paranoid thoughts

17. Nurse Taylor is aware that the victims of domestic violence should be assessed for what important information? A. Reasons they stay in the abusive relationship (for example, lack of financial autonomy and isolation) B. Readiness to leave the perpetrator and knowledge of resources C. Use of drugs or alcohol D. History of previous victimization

B. Readiness to leave the perpetrator and knowledge of resources Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready.

A client has a history of chronic undifferentiated schizophrenia. Because she has a history of noncompliance with antipsychotic therapy, she'll receive fluphenazine decanoate (Prolixin Deconoate) injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan? A. asking the physician for droperidol (Inapsine) to control any extrapyramidal symptoms that occur B. Sitting up for a few minutes before standing to minimize orthostatic hypotenison C. Notifying the physician if her thoughts don't normalize in a week D. Expecting symptoms of tardive dyskinesia to occur and to be transient

B. Sitting up for a few minutes before standing to minimize orthostatic hypotenison

14. Malou with schizophrenia tells Nurse Melinda, "My intestines are rotted from worms chewing on them." This statement indicates a: A. Jealous delusion B. Somatic delusion C. Delusion of grandeur D. Delusion of persecution

B. Somatic delusions focus on bodily functions or systems and commonly include delusion about foul odor emissions, insect manifestations, internal parasites and misshapen parts.

Which goal is a priority for a client with a DSM-IV-TR diagnosis of delirium and the nursing diagnosis: Acute confusion related to recent surgery secondary to traumatic hip fracture? A. The client will complete ADLs B. The client will maintain safety C. The client will remain oriented D. he client will understand communication

B. The client will maintain safety

32. A 25 -year old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority? A. The client will commit to a drug-free lifestyle B. The client will work with the nurse to remain safe C. The client will drink plenty of fluids daily D. The client will make a personal inventory of strength

B. The client will work with the nurse to remain safe The priority goal in alcohol withdrawal is maintaining the client's safety.

45. Nurse Bea notices a female client sitting alone in the corner smiling and talking to herself. Realizing that the client is hallucinating. Nurse Bea should: A. Invite the client to help decorate the dayroom B. Leave the client alone until he stops talking C. Ask the client why he is smiling and talking D. Tell the client it is not good for him to talk to himself

B. This provides a stimulus that competes with and reduces hallucination.

A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven effective for hallucinating patients is to: A. take an as needed dose of psychotic medication whenever they hear voices. B. practice saying "Go away" or "stop" when they hear the voices C. Sing loudly to drown out the voices and provide distractions D. go to their room until the voices go away

B. practice saying "Go away" or "stop" when they hear the voices

During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of: A. somatic delusions B. waxy flexibility C. neologisms D. nihilistic delusions

B. waxy flexibility

27. A 14-year-old client was brought to the clinic by her mother. Her mother expresses concern about her daughter's weight loss and constant dieting. Nurse Kris conducts a health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa? A. "I like the way I look. I just need to keep my weight down because I'm a cheerleader." B. "I don't like the food my mother cooks. I eat plenty of fast food when I'm out with my friends." C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." D. "I do diet around my periods; otherwise, I just get so bloated."

C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down to a "desirable weight" is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor self-esteem.

28. Jose who is receiving monoamine oxidase inhibitor antidepressant should avoid tyramine, a compound found in which of the following foods? A. Figs and cream cheese B. Fruits and yellow vegetables C. Aged cheese and Chianti wine D. Green leafy vegetables

C. Aged cheese and Chianti wine contain high concentrations of tyramine.

A client who has been hospitalized with disorganized type schizophrenia for 8 years can't complete ADLs without staff direction or assistance. The nurse formulates a nursing diagnosis or self-care deficient: Dressing/grooming related to inability to function without assistance. What is an appropriate goal for the client? A. Client will be able to complete the ADLs independently within 1 month B. Client will be able to complete ADLs with only verbal encouragement within 1 month C. Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month D. Client will be able to complete ADLs with complete assistance within 1 month

C. Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month

Important teaching for women in their childbearing years who are receiving antipsychotic medications includes which of the following? A. Occurrence of increased libido due to medication adverse effects B. Increased incidence of dysmenorrhea while taking the drug C. Continuing previous use of contraception during periods of amenorrhea D. Instruction that amenorrhea is irreversible

C. Continuing previous use of contraception during periods of amenorrhea

42. Nurse Penny is aware that the following medical conditions is commonly found in clients with bulimia nervosa? A. Allergies B. Cancer C. Diabetes mellitus D. Hepatitis A

C. Diabetes mellitus Bulimia nervosa can lead to many complications, including diabetes, heart disease, and hypertension.

A psychotic client reports to the evening nursing that the day nurse put something suspicious in his water with his medication. The nurse replies, "You're worried about your medication?" The nurses communication is: A. An example of presenting reality B. Reinforcing the client's delusions C. focusing on emotional content D. a non-therapeutic technique called mind reading

C. Focusing on emotional content

4. When teaching Mario with a typical depression about foods to avoid while taking phenelzine(Nardil), which of the following would the nurse in charge include? A. Roasted chicken B. Fresh fish C. Salami D. Hamburger

C. Foods high in tyramine, those that are fermented, pickled, aged, or smoked must be avoided because when they are ingested in combination with MAOIs a hypertensive crisis will occur.

A client is receiving haloperidol (Haldol) to reduce psychotic symptoms. As he watches television with other clients, the nurse notes that he has trouble sitting still. He seems restless, constantly moving his hands and feet and changing position. When the nurse asks what is wrong, he says he feels jittery. How should the nurse manage this situation? A. Ask the client to sit still or leave the room because he is distracting other clients B. Ask the client if he is nervous or anxious about something C. Give an as needed dose of prescribed anticholinergic medication to control akathisia. D. Administer an as needed dose of haloperidol to decrease agitation.

C. Give an as needed dose of prescribed anticholinergic medication to control akathisia.

A client tells the nurse that the television newscaster is sending a secret message to her. The nurse suspects the client is experiencing: A. a delusion B. flight of ideas C. ideas of reference D. a hallucination

C. ideas of reference

28. Nurse Fey is aware that the drug of choice for treating Tourette syndrome? A. Fluoxetine (Prozac) B. Fluvoxamine (Luvox) C. Haloperidol (Haldol) D. Paroxetine (Paxil)

C. Haloperidol (Haldol) Haloperidol is the drug of choice for treating Tourette syndrome.

48. Macoy and Helen seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. When intervening with this couple, nurse Gerry knows they are at risk for repeated violence because the husband: A. Has only moderate impulse control B. Denies feelings of jealousy or possessiveness C. Has learned violence as an acceptable behavior D. Feels secure in his relationship with his wife

C. Has learned violence as an acceptable behavior Family violence usually is a learned behavior, and violence typically leads to further violence, putting this couple at risk.

Which is the best indicator of success in the long-term management of the client? A. His symptoms are replaced by indifference to his feelings B. He participates in diversionary activities C. He learns to verbalize his feelings and concerns D. He states that his behavior is irrational

C. He learns to verbalize his feelings and concerns

2. Nurse Tamara is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: A. Avoid shopping for large amounts of food B. Control eating impulses C. Identify anxiety-causing situations D. Eat only three meals per day

C. Identify anxiety-causing situations Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.

A client with delusional thinking shows lack of interest in eating at meal times. Sh estates that she is unworthy of eating and that her children will die if she eats. Which nursing action would be most appropriate for this client? A. Telling the client that she may become sick and die unless she eats B. Paying special attention to the clients rituals and emotions associated with meals C. Restricting the client's access to food except at specified meal and snack times D. Encouraging the client to express her feelings at meal times

C. Restricting the client's access to food except at specific meal and snack times

12. Nurse Mary is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important? A. Fill out the client's menu and make sure she eats at least half of what is on her tray. B. Let the client eat her meals in private. Then engage her in social activities for at least 2 hours after each meal C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal D. Let the client eat food brought in by the family if she chooses, but she should keep a strict calorie count.

C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal Allowing the client to select her own food from the menu will help her feel some sense of control.

44. A male client who reportedly consumes one (1) qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, Dr. Smith is most likely to prescribe which drug? A. Clozapine (Clozaril) B. Thiothixene (Navane) C. Lorazepam (Ativan) D. Lithium carbonate (Eskalith)

C. Lorazepam (Ativan) The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine.

25. Clonidine (Catapres) can be used to treat conditions other than hypertension. Nurse Sally is aware that the following conditions might the drug be administered? A. Phencyclidine (PCP) intoxication B. Alcohol withdrawal C. Opiate withdrawal D. Cocaine withdrawal

C. Opiate withdrawal Clonidine is used as adjunctive therapy in opiate withdrawal.

39. A female client begins to experience alcoholic hallucinosis. Nurse Joy is aware that the best nursing intervention at this time? A. Keeping the client restrained in bed B. Checking the client's blood pressure every 15 minutes and offering juices C. Providing a quiet environment and administering medication as needed and prescribed D. Restraining the client and measuring blood pressure every 30 minutes

C. Providing a quiet environment and administering medication as needed and prescribed Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment for reducing stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing oversedation.

31. Joy's stream of consciousness is occupied exclusively with thoughts of her father's death. Nurse Ronald should plan to help Joy through this stage of grieving, which is known as: A. Shock and disbelief B. Developing awareness C. Resolving the loss D. Restitution

C. Resolving a loss is a slow, painful, continuous process until a mental image of the dead person, almost devoid of negative or undesirable features emerges.

35. A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on this finding, the nurse Lenny should formulate a nursing diagnosis of: A. Ineffective individual coping related to feelings of guilt. B. Situational low self-esteem related to feelings of loss of control C. Risk for violence: Self-directed related to impulsive mutilating acts D. Risk for violence: Directed toward others related to verbal threats

C. Risk for violence: Self-directed related to impulsive mutilating acts The predominant behavioral characteristic of the client with borderline personality disorder is impulsiveness, especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn't substantiate the other options.

16. Nurse Harry is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan? A. Restrict visits with the family until the client begins to eat B. Provide privacy during meals C. Set up a strict eating plan for the client D. Encourage the client to exercise, which will reduce her anxiety

C. Set up a strict eating plan for the client Establishing a consistent eating plan and monitoring the client's weight are important for this disorder.

A clinical instructor is correcting a nursing student's worksheet. Which instructor statement is the best example of effective feedback? A. Why did you use the client's name on your clinical worksheet? B. You were very careless to refer to your client by name on your clinical worksheet. C. Surely you didn't do it deliberately, but you breached confidentiality by using the client's name. D. It is disappointing that after being told, you're still using client names on your worksheet.

C. Surely you didn't do it deliberately, but you breached confidentiality by using the client's name.

23. Which of the following drugs have been known to be effective in treating obsessive-compulsive disorder (OCD)? A. Divalproex (depakote) and Lithium (lithobid) B. Chlordiazepoxide (Librium) and diazepam (valium) C. Fluvoxamine (Luvox) and clomipramine (anafranil) D. Benztropine (Cogentin) and diphenhydramine (benadryl)

C. The antidepressants fluvoxamine and clomipramine have been effective in the treatment of OCD.

19. A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused? A. The child cries uncontrollably throughout the examination B. The child pulls away from contact with the physician. C. The child doesn't cry when the shoulder is examined D. The child doesn't make eye contact with the nurse.

C. The child doesn't cry when the shoulder is examined A characteristic behavior of abused children is the lack of crying when they undergo a painful procedure or are examined by a health care professional. Therefore, the nurse should suspect child abuse.

39. A client with depression has been hospitalized for treatment after taking a leave of absence from work. The client's employer expects the client to return to work following inpatient treatment. The client tells the nurse, "I'm no good. I'm a failure". According to cognitive theory, these statements reflect: A. Learned behavior B. Punitive superego and decreased self-esteem C. Faulty thought processes that govern behavior D. Evidence of difficult relationships in the work environment

C. The client is demonstrating faulty thought processes that are negative and that govern his behavior in his work situation - issues that are typically examined using a cognitive theory approach. Issues involving learned behavior are best explored through behavior theory, not cognitive theory. Issues involving ego development are the focus of psychoanalytic theory. Option 4 is incorrect because there is no evidence in this situation that the client has conflictual relationships in the work environment.

38. A nurse who explains that a client's psychotic behavior is unconsciously motivated understands that the client's disordered behavior arises from which of the following? A. Abnormal thinking B. Altered neurotransmitters C. Internal needs D. Response to stimuli

C. The concept that behavior is motivated and has meaning comes from the psychodynamic framework. According to this perspective, behavior arises from internal wishes or needs. Much of what motivates behavior comes from the unconscious. The remaining responses do not address the internal forces thought to motivate behavior.

30. The initial nursing intervention for the significant-others during shock phase of a grief reaction should be focused on: A. Presenting full reality of the loss of the individuals B. Directing the individual's activities at this time C. Staying with the individuals involved D. Mobilizing the individual's support system

C. This provides support until the individuals coping mechanisms and personal support systems can be immobilized.

10. Nurse Ronald could evaluate that the staff's approach to setting limits for a demanding, angry client was effective if the client: A. Apologizes for disrupting the unit's routine when something is needed B. Understands the reason why frequent calls to the staff were made C. Discuss concerns regarding the emotional condition that required hospitalizations D. No longer calls the nursing staff for assistance

C. This would document that the client feels comfortable enough to discuss the problems that have motivated the behavior.

A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism? A. Restlessness, difficulty swallowing, and pacing B. Involuntary rolling of the eyes C. Tremors, shuffling gait, and masklike face D. Extremity and neck spasms, facial grimacing, and jerky movements

C. Tremors, shuffling gait and masklike face

1. Nurse Tony should first discuss terminating the nurse-client relationship with a client during the: A. Termination phase when discharge plans are being made. B. Working phase when the client shows some progress. C. Orientation phase when a contract is established. D. Working phase when the client brings it up.

C. When the nurse and client agree to work together, a contract should be established, the length of the relationship should be discussed in terms of its ultimate termination.

33. Important teaching for women in their childbearing years who are receiving antipsychotic medications includes which of the following? A. Increased incidence of dysmenorrhea while taking the drug B. Occurrence of incomplete libido due to medication adverse effects C. Continuing previous use of contraception during periods of amenorrhea D. Instruction that amenorrhea is irreversible

C. Women may experience amenorrhea, which is reversible, while taking antipsychotics. Amenorrhea doesn't indicate cessation of ovulation thus, the client can still be pregnant.

The definition of nihilistic delusions is: A. a false belief about what the functioning of the body B. belief that the body is deformed or defective in a specific way C. false ideas about the self, others, or the world D. the inability to carry out motor activities

C. false ideas about the self, others, or the world

A client with chronic schizophrenia who takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These findings suggest which life-threatening reaction: A. tardive dyskinesia B. dystonia C. neuroleptic malignant syndrome D. akathisia

C. neuroleptic malignant syndrome

A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a: A. delusion of persecution B. delusion of grandeur C. somatic delusion D. jealous delusion

C. somatic delusion

When planning care for a client who has ingested phencyclidine (PCP), nurse Wayne is aware that the following is the highest priority?

Client's safety needs

Lucille has a diagnosis of somatic symptom disorder, predominantly pain. Which of the following medications would the psychiatric nurse practitioner most likely prescribe for Lucille?

D) duloxetine (cymbalta)

Nursing care for a client with somatic symptom disorder would focus on helping her to

D) learn more adaptive coping strategies

Ellen has a history of childhood physical and sexual abuse. She was diagnosed with dissociative identity disorder 6 years ago. She has been admitted to the psychiatric unit following a suicide attempt. The primary nursing diagnosis for Ellen would be

D) risk for suicide related to unresolved grief

4. Which of the following drugs should Nurse Mary prepare to administer to a client with a toxic acetaminophen (Tylenol) level? A. Deferoxamine mesylate (Desferal )B. Succimer (Chemet) C. Flumazenil (Romazicon) D. Acetylcysteine (Mucomyst)

D. Acetylcysteine (Mucomyst) The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites.

A dopamine receptor agonist such as bromocriptine (Parlodel) relieves muscle rigidity activity caused by antipsychotic medication by: A. Blocking dopamine receptors in the CNS B. Blocking acetylcholine in the CNS C. Activating norepinephrine in the CNS D. Activating dopamine receptors in the CNS

D. Activating dopamine receptors in the CNS

13. Jon a suspicious client states that "I know you nurses are spraying my food with poison as you take it out of the cart." Which of the following would be the best response of the nurse? A. Giving the client canned supplements until the delusion subsides B. Asking what kind of poison the client suspects is being used C. Serving foods that come in sealed packages D. Allowing the client to be the first to open the cart and get a tray

D. Allowing the client to be the first to open the cart & take a tray presents the client with the reality that the nurses are not touching the food & tray, thereby dispelling the delusion.

40. The nurse describes a client as anxious. Which of the following statement about anxiety is true? A. Anxiety is usually pathological B. Anxiety is directly observable C. Anxiety is usually harmful D. Anxiety is a response to a threat

D. Anxiety is a response to a threat arising from internal or external stimuli.

5. A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is Nurse Alice most likely to administer to reduce the symptoms of alcohol withdrawal? A. Naloxone (Narcan) B. Haloperidol (Haldol) C. Magnesium sulfate D. Chlordiazepoxide (Librium)

D. Chlordiazepoxide (Librium) Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal.

While looking out the window, a client with schizophrenia remarks, "That school across the street has creatures in it that are waiting for me." Which of the following terms best describes what the creatures represent? A. Anxiety attack B. Projection C. Hallucination D. Delusion

D. Delusion

7. Danny who is diagnosed with bipolar disorder and acute mania, states the nurse, "Where is my daughter? I love Louis. Rain, rain go away. Dogs eat dirt." The nurse interprets these statements as indicating which of the following? A. Echolalia B. Neologism C. Clang associations D. Flight of ideas

D. Flight of ideas is speech pattern of rapid transition from topic to topic, often without finishing one idea. It is common in mania.

The nurse asks a client to roll up his sleeves so she can take his blood pressure. The client replies, "If you want I can go naked for you." The most therapeutic response by the nurse is: A. You're attractive, but I'm not interested. B. You wouldn't be the first person I've seen naked. C. I will report you to the guard if you don't control yourself. D. I only need access to your arm. Putting up your sleeve is fine.

D. I only need access to your arm. Putting up your sleeve is fine.

43. The nurse is caring for a client with an autoimmune disorder at a medical clinic, where alternative medicine is used as an adjunct to traditional therapies. Which information should the nurse teach the client to help foster a sense of control over his symptoms? A. Pathophysiology of disease process B. Principles of good nutrition C. Side effects of medications D. Stress management techniques

D. In autoimmune disorders, stress and the response to stress can exacerbate symptoms. Stress management techniques can help the client reduce the psychological response to stress, which in turn will help reduce the physiologic stress response. This will afford the client an increased sense of control over his symptoms. The nurse can address the remaining answer choices in her teaching about the client's disease and treatment; however, knowledge alone will not help the client to manage his stress effectively enough to control symptoms.

18. Which of the following statements should be included when teaching clients about monoamine oxidase inhibitor (MAOI) antidepressants? A. Don't take aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) B. Have blood levels screened weekly for leucopenia C. Avoid strenuous activity because of the cardiac effects of the drug D. Don't take prescribed or over the counter medications without consulting the physician

D. MAOI antidepressants when combined with a number of drugs can cause life-threatening hypertensive crisis. It's imperative that a client checks with his physician and pharmacist before taking any other medications.

21. Which of the following assessment would provide the best information about the client's physiologic response and the effectiveness of the medication prescribed specifically for alcohol withdrawal? A. Sleeping pattern B. Mental alertness C. Nutritional status D. Vital signs

D. Monitoring of vital signs provides the best information about the client's overall physiologic status during alcohol withdrawal & the physiologic response to the medication used.

14. A 24-year old client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and feelings? A. Avoid discussing the client's perceptions and feelings B. Focus discussions on food and weight C. Avoid discussing unrealistic cultural standards regarding weight D. Provide objective data and feedback regarding the client's weight and attractiveness

D. Provide objective data and feedback regarding the client's weight and attractiveness By focusing on reality, this strategy may help the client develop a more realistic body image and gain self-esteem.

31. Nurse Fred is assessing a client who has just been admitted to the ER department. Which signs would suggest an overdose of an antianxiety agent? A. Suspiciousness, dilated pupils and incomplete BP B. Agitation, hyperactivity and grandiose ideation C. Combativeness, sweating and confusion D. Emotional lability, euphoria and impaired memory

D. Signs of anxiety agent overdose include emotional lability, euphoria and impaired memory.

44. One morning, nurse Diane finds a disturbed client curled up in the fetal position in the corner of the dayroom. The most accurate initial evaluation of the behavior would be that the client is: A. Physically ill and experiencing abdominal discomfort B. Tired and probably did not sleep well last night C. Attempting to hide from the nurse D. Feeling more anxious today

D. The fetal position represents regressed behavior. Regression is a way of responding to overwhelming anxiety.

34. A client refuses to remain on psychotropic medications after discharge from an inpatient psychiatric unit. Which information should the community health nurse assess first during the initial follow-up with this client? A. Income level and living arrangements B. Involvement of family and support systems C. Reason for inpatient admission D. Reason for refusal to take medications

D. The first are for assessment would be the client's reason for refusing medication. The client may not understand the purpose for the medication, may be experiencing distressing side effects, or may be concerned about the cost of medicine. In any case, the nurse cannot provide appropriate intervention before assessing the client's problem with the medication. The patient's income level, living arrangements, and involvement of family and support systems are relevant issues following determination of the client's reason for refusing medication. The nurse providing follow-up care would have access to the client's medical record and should already know the reason for inpatient admission.

Which nursing statement is a good example of the therapeutic communication technique of focusing? A. Describe one of the best things that happened to you this week. B. I'm having a difficult time understanding what you mean. C. Your counseling session is in 30 minutes. I'll stay with you until then. D. You mentioned your relationship with your father. Let's discuss that further.

D. You mentioned your relationship with your father. Let's discuss that further.

A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing: A. a delusion B. flight of ideas C. ideas of reference D. a hallucination

D. a hallucination

Nursing care for a client with schizophrenia must be based on valid psychiatric and nursing theories. The nurse's interpersonal communication with the client and specific nursing interventions must be: A. clearly identified with boundaries and specifically defined roles B. warm and non-threatening C. centered on clearly defined limits and expression of empathy D. flexible enough for the nurse to adjust the plan of care as the situation warrants

D. flexible enough for the nurse to adjust the plan of care as the situation warrants

A client is admitted to the psychiatric unit of a local hospital with chronic undifferentiated schizophrenia. During the next several days, the client is seen laughing, yelling, and talking to herself. This behavior is characteristic of: A. delusion B. looseness of association C. illusion D. hallucinations

D. hallucinations

A 60-year-old female client who lives alone tells the nurse at the community health center "I really don't need anyone to talk to". The TV is my best friend. The nurse recognizes that the client is using the defense mechanism known as?

Denial Explanation: Option D: The client statement is an example of the use of denial, a defense that blocks problem by unconscious refusing to admit they exist.

A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate (Prolixin Decanoate) by I.M. injection. Three days later, the client has muscle contractions that contort the neck. This client is exhibiting which extrapyramidal reaction?

Dystonia

Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia are?

Excessive weight loss, amenorrhea & abdominal distension

A 39-year-old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often:

Feelings of guilt and inadequacy Explanation: Option C: Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior.

A 75-year-old client has dementia of the Alzheimer's type and confabulates. The nurse understands that this client:

Fills in memory gaps with fantasy.

Positive symptoms of schizophrenia include which of the following?

Hallucinations, delusions, and disorganized thinking

Which statement by the client during the initial assessment in the the emergency department is most indicative for suspected domestic violence?

I have tried leaving, but have always gone back."

Malingering is different from somatoform disorder because the former:

It is a deliberate effort to handle upsetting events Explanation: Malingering is a conscious simulation of an illness while somatoform disorder occurs unconscious.

Aldo, with a somatoform pain disorder may obtain secondary gain. Which of the following statement refers to a secondary gain?

It promotes emotional support or attention for the client. Explanation: D: Secondary gain refers to the benefits of the illness that allow the client to receive emotional support or attention. C: Primary gain enables the client to avoid some unpleasant activity

The nurse evaluates the treatment of Mrs. Montez with somatoform disorder as successful if:

Mrs. Montez verbalizes anxiety directly rather than displacing it.

The nurse is aware that antipsychotic medications may cause which of the following adverse effects?

Lower seizure threshold

Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to:

Manipulate the environment to bring about positive changes in behavior

Nurse Trish is working in a mental health facility; the nurse's priority nursing intervention for a newly admitted client with bulimia nervosa would be...

Monitor client continuously Explanation: Option D: These clients often hide food or force vomiting; therefore they must be carefully monitored.

A client diagnosed with schizoaffective disorder is suffering from schizophrenia with elements of which of the following disorders?

Mood disorder

Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the:

Name of the ingested medication & the amount ingested

A client is admitted with needle tracts on his arm, stuporous and with pin point pupil will likely be managed with:

Narcan (Naloxone) Explanation: Narcan is a narcotic antagonist used to manage the CNS depression due to overdose with heroin

Nurse Jannah is monitoring a male client who has been placed in restraints because of violent behavior. Nurse determines that it will be safe to remove the restraints when:

No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints.

A client who's actively hallucinating is brought to the hospital by friends. They say that the client used either lysergic acid diethylamide (LSD) or angel dust (phencyclidine [PCP]) at a concert. Which of the following common assessment findings indicates that the client may have ingested PCP?

Nystagmus

Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to the restroom, Nurse Monet should...

Observe her Explanation: Option D: The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurse should watch for clues, such as communicating suicidal thoughts, and messages; hoarding medications and talking about death.

Nurse Amy is aware that the client is at highest risk for suicide?

One who plans a violent death and has the means readily available Explanation: The client at highest risk for suicide is one who plans a violent death (for example, by gunshot, jumping off a bridge, or hanging), has a specific plan (for example, after the spouse leaves for work), and has the means readily available (for example, a rifle hidden in the garage)

A nursing care plan for a male client with bipolar I disorder should include:

Providing a structured environment

The nurse is interacting with a family consisting of a mother, a father, and a hospitalized adolescent who has a diagnosis of alcohol abuse. The nurse analyzes the situation and agrees with the adolescent's view about family rules. Which intervention is most appropriate?

The nurse should remain objective and encourage mutual negotiation of issues.

A nurse is evaluating therapy with the family of a client with anorexia nervosa. Which of the following would indicate that the therapy was successful?

The parents reinforce increased decision making by the client. Explanation: One of the core issues concerning the family of a client with anorexia is control. The family's acceptance of the client's ability to make independent decisions is key to successful family intervention. Although the remaining options may occur during the process of therapy they would not necessarily indicate a successful outcome; the central family issues of dependence and independence are not addressed in these responses.

Kellan, a high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome?

The student accepts a referral to a substance abuse counselor

Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of heroin withdrawal?

Vomiting and Diarrhea Explanation: Option D: Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle spasm, fever, nausea, repetitive, abdominal cramps, and backache.

A student nurse is caring for a 75-year-old client who is very confused. The student's communication tools should include:

gentle touch while guiding ADLs (activities of daily living)

A client with paranoid personality disorder is admitted to a psychiatric facility. Which remark by the nurse would best establish rapport and encourage the client to confide in the nurse?

"I get upset once in a while, too."

A 15-year-old girl with anorexia has been admitted to a mental health unit. She refuses to eat. Which of the following statements is the best response from the nurse?

"I hope you'll eat your food by mouth. Tube feedings and I.V. lines can be uncomfortable

A 14-year-old client is brought to the clinic by her mother. Her mother expresses concern about her daughter's weight loss and constant dieting. Nurse Kris conducts a health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa?

"I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls."

A 14-year-old client is brought to the clinic by her mother. Her mother expresses concern about her daughter's weight loss and constant dieting. Nurse Kris conducts a health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa?

"I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." Explanation: Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down to a "desirable weight" is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor self-esteem. Most clients with anorexia nervosa don't like the way they look, and their self-perception may be distorted.

A male client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse Linda, which statement by the client most strongly supports a diagnosis of psychoactive substance abuse?

"I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me."

During postprandial monitoring, a female client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response?

"I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."

What would be the best response to the client's repeated complaints of pain:

"I know the feeling is real tests revealed negative results.

Nurse Tina is caring for a client with delirium and states that "look at the spiders on the wall". What should the nurse respond to the client?

"I know you are frightened, but I do not see spiders on the wall" Explanation: Option D: When hallucination is present, the nurse should reinforce reality with the client.

1. Francis who is addicted to cocaine withdraws from the drug. Nurse Ron should expect to observe: A. Hyperactivity B. Depression C. Suspicion D. Delirium

B. There is no set of symptoms associated with cocaine withdrawal, only the depression that follows the high caused by the drug.

Which outcome is most appropriate for Brooklyn who has a dissociative disorder?

Brooklyn will use problem-solving strategies when feeling stressed.

The nurse observes a client pacing in the hall. Which statement by the nurse may help the client recognize his anxiety?

"I notice that you're pacing. How are you feeling?" Question 3 Explanation: By acknowledging the observed behavior and asking the client to express his feelings the nurse can best assist the client to become aware of his anxiety.

A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills in the client's drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be

"Tell me about your week prior to being admitted." Explanation: This is an open-ended question which is non-judgemental and allows for further discussion. The topic is also nonthreatening yet will give the nurse insight into the client"s view of events leading up to admission. It is the only option that is client centered

A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from nurse Julia?

"Tell me how you feel about the accident."

During a private conversation, a client with borderline personality disorder asks the nurse to keep his secret and then displays multiple, self-inflicted, superficial lacerations on the forearms. What is the nurse's best response?

"The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."

She tearfully tells the nurse "I can't take it when she accuses me of stealing her things." Which response by the nurse will be most therapeutic?

"This must be difficult for you and your mother." Explanation: This reflecting the feeling of the daughter that shows empathy.

A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be most helpful in dealing with the client's anger?

"You had to wait. Can we talk about how this is making you feel right now?"

Which of these statements by the nurse reflects the best use of therapeutic interaction techniques?

"You look upset. Would you like to talk about it?"

A client with a history of substance abuse has been attending Alcoholics Anonymous meetings regularly in the psychiatric unit. One afternoon, the client tells the nurse, "I'm not going to those meetings anymore. I'm not like the rest of those people. I'm not a drunk. "What is the most appropriate response?

"You seem upset about the meetings."

A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response?

"You told me you got fired from your last job for missing too many days after taking drugs all night."

A client with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be most appropriate?

"Your behavior won't be tolerated. Go to your room immediately." Option A: The nurse should set limits on client behavior to ensure a comfortable environment for all clients.

She says to the nurse who offers her breakfast, "Oh no, I will wait for my husband. We will eat together" The therapeutic response by the nurse is:

"Your husband is dead. Let me serve you your breakfast."

The nurse can BEST ensure the safety of a demented client who wanders from the room by

Attaching a wander-guard sensor band to the client's wrist

Which of the following would best indicate to the nurse that a depressed client is improving?

Changes in vegetative signs

36. When developing an initial nursing care plan for a male client with a Bipolar I disorder (manic episode) nurse Ron should plan to? A. Isolate his gym time B. Encourage his active participation in unit programs C. Provide foods, fluids and rest D. Encourage his participation in programs

C. The client in a manic episode of the illness often neglects basic needs, these needs are a priority to ensure adequate nutrition, fluid, and rest.

21. The nurse is aware that the outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder? A. Accept responsibility for own behaviors B. Be able to verbalize own needs and assert rights. C. Set firm and consistent limits with the client D. Allow the child to establish his own limits and boundaries

A. Accept responsibility for own behaviors Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child.

22. After administering naloxone (Narcan), an opioid antagonist, Nurse Ronald should monitor the female client carefully for which of the following? A. Respiratory depression B. Epilepsy C. Kidney failure D. Cerebral edema

A. After administering naloxone (Narcan) the nurse should monitor the client's respiratory status carefully, because the drug is short acting & respiratory depression may recur after its effects wear off.

45. A male client is being treated for alcoholism. After a family meeting, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. Nurse Lily should suggest that the family join which organization? A. Al-Anon B. Make Today Count C. Emotions Anonymous D. Alcoholics Anonymous

A. Al-Anon Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism.

5. When assessing a female client who is receiving tricyclic antidepressant therapy, which of the following would alert the nurse to the possibility that the client is experiencing anticholinergic effects? A. Urine retention and blurred vision B. Respiratory depression and convulsion C. Delirium and Sedation D. Tremors and cardiac arrhythmias

A. Anticholinergic effects, which result from blockage of the parasympathetic (craniosacral) nervous system including urine retention, blurred vision, dry mouth & constipation.

5. Before helping a male client who has been sexually assaulted, nurse Maureen should recognize that the rapist is motivated by feelings of: A. Hostility B. Inadequacy C. Incompetence D. Passion

A. Rapists are believed to harbor and act out hostile feelings toward all women through the act of rape.

3. A female client who's at high risk for suicide needs close supervision. To best ensure the client's safety, Nurse Mary should: A. Check the client frequently at irregular intervals throughout the night B. Assure the client that the nurse will hold in confidence anything the client says C. Repeatedly discuss previous suicide attempts with the client D. Disregard decreased communication by the client because this is common with suicidal clients

A. Check the client frequently at irregular intervals throughout the night Checking the client frequently but at irregular intervals prevents the client from predicting when observation will take place and altering behavior in a misleading way at these times.

36. A male client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. Nurse Ryan notes a rise in the client's arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use? A. Coronary artery spasm B. Bradyarrhythmias C. Neurobehavioral deficits D. Panic disorder

A. Coronary artery spasm Cocaine use may cause such cardiac complications as coronary artery spasm, myocardial infarction, dilated cardiomyopathy, acute heart failure, endocarditis, and sudden death. Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of these neurotransmitters at postsynaptic receptor sites.

40. Nurse Bella is aware that assessment finding is most consistent with early alcohol withdrawal? A. Heart rate of 120 to 140 beats/minute B. Heart rate of 50 to 60 beats/minute C. Blood pressure of 100/70 mmHg D. Blood pressure of 140/80 mmHg

A. Heart rate of 120 to 140 beats/minute Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs carefully throughout the entire alcohol withdrawal process.

34. Jerome who has eating disorder often exhibits similar symptoms. Nurse Lhey would expect an adolescent client with anorexia to exhibit: A. Affective instability B. Dishered, unkempt physical appearance C. Depersonalization and derealization D. Repetitive motor mechanisms

A. Individuals with anorexia often display irritability, hospitality, and a depressed mood.

46. A nurse is evaluating therapy with the family of a client with anorexia nervosa. Which of the following would indicate that the therapy was successful? A. The parents reinforced increased decision making by the client B. The parents clearly verbalize their expectations for the client C. The client verbalizes that family meals are now enjoyable D. The client tells her parents about feelings of low-self esteem

A. One of the core issues concerning the family of a client with anorexia is control. The family's acceptance of the client's ability to make independent decisions is key to successful family intervention. Although the remaining options may occur during the process of therapy, they would not necessarily indicate a successful outcome; the central family issues of dependence and independence are not addresses on these responses.

12. When nurse Hazel considers a client's placement on the continuum of anxiety, a key in determining the degree of anxiety being experienced is the client's: A. Perceptual field B. Delusional system C. Memory state D. Creativity level

A. Perceptual field is a key indicator of anxiety level because the perceptual fields narrow as anxiety increases.

8. The most critical factor for nurse Linda to determine during crisis intervention would be the client's: A. Available situational supports B. Willingness to restructure the personality C. Developmental theory D. Underlying unconscious conflict

A. Personal internal strength and supportive individuals are critical factors that can be employed to assist the individual to cope with a crisis.

24. Tony with agoraphobia has been symptom-free for 4 months. Classic signs and symptoms of phobia include: A. Severe anxiety and fear B. Withdrawal and failure to distinguish reality from fantasy C. Depression and weight loss D. Insomnia and inability to concentrate

A. Phobias cause severe anxiety (such as panic attack) that is out of proportion to the threat of the feared object or situation. Physical signs and symptoms of phobias include profuse sweating, poor motor control, tachycardia and elevated B.P.

30. Barbara with bipolar disorder is being treated with lithium for the first time. Nurse Clint should observe the client for which common adverse effect of lithium? A. Polyuria B. Seizures C. Constipation D. Sexual dysfunction

A. Polyuria commonly occurs early in the treatment with lithium and could result in fluid volume deficit.

47. Nurse John recognizes that paranoid delusions usually are related to the defense mechanism of: A. Projection B. Identification C. Repression D. Regression

A. Projection is a mechanism in which inner thoughts and feelings are projected onto the environment, seeming to come from outside the self rather than from within.

38. Nurse Helen is assigned to care for a client with anorexia nervosa. Initially, which nursing intervention is most appropriate for this client? A. Providing one-on-one supervision during meals and for one (1) hour afterward B. Letting the client eat with other clients to create a normal mealtime atmosphere C. Trying to persuade the client to eat and thus restore nutritional balance D. Giving the client as much time to eat as desired

A. Providing one-on-one supervision during meals and for one (1) hour afterward Because the client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 hour afterward.

15. Nurse Hazel invites new client's parents to attend the psycho educational program for families of the chronically mentally ill. The program would be most likely to help the family with which of the following issues? A. Developing a support network with other families B. Feeling more guilty about the client's illness C. Recognizing the client's weakness D. Managing their financial concern and problems

A. Psychoeducational groups for families develop a support network. They provide education about the biochemical etiology of psychiatric disease to reduce, not increase family guilt.

41. A client with a phobic disorder is treated by systematic desensitization. The nurse understands that this approach will do which of the following? A. Help the client execute actions that are feared B. Help the client develop insight into irrational fears C. Help the client substitutes one fear for another D. Help the client decrease anxiety

A. Systematic desensitization is a behavioral therapy technique that helps clients with irrational fears and avoidance behavior to face the thing they fear, without experiencing anxiety. There is no attempt to promote insight with this procedure, and the client will not be taught to substitute one fear for another. Although the client's anxiety may decrease with successful confrontation of irrational fears, the purpose of the procedure is specifically related to performing activities that typically are avoided as part of the phobic response.

50. Which activity would be most appropriate for a severely withdrawn client? A. Art activity with a staff member B. Board game with a small group of clients C. Team sport in the gym D. Watching TV in the dayroom

A. The best approach with a withdrawn client is to initiate brief, nondemanding activities on a one-to-one basis. This approach gives the nurse an opportunity to establish a trusting relationship with the client. A board game with a group clients or playing a team sport in the gym may overwhelm a severely withdrawn client. Watching TV is a solitary activity that will reinforce the client's withdrawal from others.

20. Initial interventions for Marco with acute anxiety include all except which of the following? A. Touching the client in an attempt to comfort him B. Approaching the client in calm, confident manner C. Encouraging the client to verbalize feelings and concerns D. Providing the client with a safe, quiet and private place

A. The emergency nurse must establish rapport and trust with the anxious client before using therapeutic touch. Touching an anxious client may actually increase anxiety.

9. When interviewing the parents of an injured child, which of the following is the strongest indicator that child abuse may be a problem? A. The injury isn't consistent with the history or the child's age B. The mother and father tell different stories regarding what happened C. The family is poor D. The parents are argumentative and demanding with emergency department personnel

A. The injury isn't consistent with the history or the child's age When the child's injuries are inconsistent with the history given or impossible because of the child's age and developmental stage, the emergency department nurse should be suspicious that child abuse is occurring.

28. When developing a plan of care for a female client with acute stress disorder who lost her sister in a car accident. Which of the following would the nurse expect to initiate? A. Facilitating progressive review of the accident and its consequences B. Postponing discussion of the accident until the client brings it up C. Telling the client to avoid details of the accident D. Helping the client to evaluate her sister's behavior

A. The nurse would facilitate progressive review of the accident and its consequence to help the client integrate feelings & memories and to begin the grieving process.

38. One morning a female client on the inpatient psychiatric service complains to nurse Hazel that she has been waiting for over an hour for someone to accompany her to activities. Nurse Hazel replies to the client "We're doing the best we can. There are a lot of other people on the unit who needs attention too." This statement shows that the nurse's use of: A. Defensive behavior B. Reality reinforcement C. Limit-setting behavior D. Impulse control

A. The nurse's response is not therapeutic because it does not recognize the client's needs but tries to make the client feel guilty for being demanding.

10. For a female client with anorexia nervosa, nurse Rose plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa? A. They tend to overprotect their children B. They usually have a history of substance abuse C. They maintain emotional distance from their children D. They alternate between loving and rejecting their children

A. They tend to overprotect their children Clients with anorexia nervosa typically come from a family with parents who are controlling and overprotective. These clients use eating to gain control of an aspect of their lives.

A schizophrenic client with delusions tells the nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusions. Which of the following would be the best response? A. This subject seems to be troubling you. Let's walk to the activity room. B. There is no reason to be afraid of that man. This hospital is very secure. C. Describe the man who's out to get you. What does he look like? D. There is no need to be concerned with a man who isn't even real.

A. This subject seems to be troubling you. Let's walk to the activity room.

11. Which of the following activities would Nurse Trish recommend to the client who becomes very anxious when thoughts of suicide occur? A. Using exercise bicycle B. Meditating C. Watching TV D. Reading comics

A. Using exercise bicycle is appropriate for the client who becomes very anxious when thoughts of suicidal occur.

A client with panic disorder experiences an acute attack while the nurse is completing an admission assessment. List the following interventions according to their level of priority. a. Remain with the client. b. Encourage physical activity. c. Encourage low, deep breathing. d. Reduce external stimuli. e. Teach coping measures.

ADCBE

The nurse is working with a client who abuses alcohol. Which of the following facts should the nurse communicate to the client?

Abstinence is the basis for successful treatment

Initial intervention for the client should be to:

Accept her fears without criticizing

The nurse is aware that the outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder?

Accept responsibility for own behaviors

A client with obsessive-compulsive disorder is hospitalized on an inpatient unit. Which nursing response is most therapeutic?

Accepting the client's obsessive-compulsive behaviors Explanation: A client with obsessive-compulsive behavior uses this behavior to decrease anxiety. Accepting this behavior as the client's attempt to feel secure is therapeutic. When a specific treatment plan is developed, other nursing responses may also be acceptable.

Since admission 4 days ago, a client has refused to take a shower, stating, "There are poison crystals hidden in the shower head. They'll kill me if I take a shower." Which nursing action is most appropriate?

Accepting these fears and allowing the client to take a sponge bath

A client with schizophrenia tells the nurse he hears the voices of his dead parents. To help the client ignore the voices, the nurse should recommend that he:

listen to a personal stereo through headphones and sing along with the music.

Which non-antipsychotic medication is used to treat some clients with schizoaffective disorder?

lithium carbonate (Lithane)

Nurse Alice is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products?

Aftershave lotion

A client taking the monoamine oxidase inhibitor (MAOI) antidepressant isocarboxazid (Marplan) is instructed by the nurse to avoid which foods and beverages?

Aged cheese and red wine

A male client is being treated for alcoholism. After a family meeting, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. Nurse Lily should suggest that the family join which organization?

Al-Anon Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism.

A male client is being treated for alcoholism. After a family meeting, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. Nurse Lily should suggest that the family join which organization?

Al-Anon Explanation: Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism.

A client with a diagnosis of paranoid schizophrenia comments to the nurse, "How do I know what is really in those pills?" Which of the following is the best response?

Allow him to open the individual wrappers of the medication

In establishing trust with Ellen, a client with the diagnosis of DID, the nurse must

B) establish a relationship with each of the personalities separately

The ultimate goal of therapy for a client with DID is most likely achieved through

B) psychotherapy and hypnosis

Lorraine, a client diagnosed with somatic symptom disorder, states, "My doctor thinks I should see a psychiatrist. I can't imagine why he would make such a suggestion." What is the basis for Lorraine's statement?A) she thinks her doctor wants to get rid of her as a clientB) she does not understand the correlation of symptoms and stressC) she thinks psychiatrists are only for "crazy" peopleD) she thinks her doctor has made an error in diagnosis

B) she does not understand the correlation of symptoms and stress

Propranolol (Inderal) is used in the mental health setting to manage which of the following conditions?

Antipsychotic-induced akathisia and anxiety

A man with a 5-year history of multiple psychiatric admissions is brought to the emergency department by the police. He was found wandering the streets disheveled, shoeless, and confused. Based on his previous medical records and current behavior, he is diagnosed with chronic undifferentiated schizophrenia. The nurse should assign the highest priority to which nursing diagnosis?

Anxiety Explanation: Option A: For this client, the highest-priority nursing diagnosis is Anxiety (severe to panic-level), manifested by the client's extreme withdrawal and attempt to protect himself from the environment. The nurse must act immediately to reduce anxiety and protect the client and others from possible injury

When working with a male client suffering phobia about black cats, Nurse Trish should anticipate that a problem for this client would be?

Anxiety when discussing phobia

29. A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from nurse Julia? A. "Why didn't you get someone else to drive you?" B. "Tell me how you feel about the accident." C. "You should know better than to drink and drive." D. "I recommend that you attend an Alcoholics Anonymous meeting."

B. "Tell me how you feel about the accident." An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings.

A client is about to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching session, the nurse should provide which instruction to the client?

Apply a sunscreen before being exposed to the sun

A male client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. How should Nurse Anuktakanuk approach her initially?

Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her

What is the best intervention to teach the client when she feels the need to starve?

Approach the nurse and talk out her feelings xplanation: The client with anorexia nervosa uses starvation as a way of managing anxiety. Talking out feelings with the nurse is an adaptive coping

Which of the following should be included in the health teachings among clients receiving Valium:

Avoid taking CNS depressant like alcohol. Explanation: Valium is a CNS depressant. Taking it with other CNS depressants like alcohol; potentiates its effect.

A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example of which behavior?

Avolition

37. Grace is exhibiting withdrawn patterns of behavior. Nurse Johnny is aware that this type of behavior eventually produces feeling of: A. Repression B. Loneliness C. Anger D. Paranoia

B. The withdrawn pattern of behavior presents the individual from reaching out to others for sharing the isolation produces feeling of loneliness.

7. A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response? A. "If you continue to talk like that, I'm going to stop speaking to you." B. "You told me you got fired from your last job for missing too many days after taking drugs all night." C. "Tell me more about how it felt to get high." D. "Don't you know it's illegal to use drugs?"

B. "You told me you got fired from your last job for missing too many days after taking drugs all night." Confronting the client with the consequences of substance abuse helps to break through denial.

42. Which client outcome would best indicate successful treatment for a client with an antisocial personality disorder? A. The client exhibits charming behavior when around authority figures B. The client has decreased episodes of impulsive behaviors C. The client makes statements of self-satisfaction D. The client's statements indicate no remorse for behaviors

B. A client with antisocial personality disorder typically has frequent episodes of acting impulsively with poor ability to delay self-gratification. Therefore, decreased frequency of impulsive behaviors would be evidence of improvement. Charming behavior when around authority figures and statements indicating no remorse are examples of symptoms typical of someone with this disorder and would not indicate successful treatment. Self-satisfaction would be viewed as a positive change if the client expresses low self-esteem; however this is not a characteristic of a client with antisocial personality disorder.

15. Nurse Alice is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products? A. Carbonated beverages B. Aftershave lotion C. Toothpaste D. Cheese

B. Aftershave lotion Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions.

24. Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. Nurse Melinda should suspect: A. A postoperative infection B. Alcohol withdrawal C. Acute sepsis. D. Pneumonia.

B. Alcohol withdrawal The client's vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome.

14. A client is suffering from catatonic behaviors. Which of the following would the nurse use to determine that the medication administered PRN have been most effective? A. The client responds to verbal directions to eat B. The client initiates simple activities without direction C. The client walks with the nurse to her room D. The client is able to move all extremities occasionally

B. Although all the actions indicate improvement, the ability to initiate simple activities without directions indicates the most improvement in the catatonic behaviors.

17. Which medication can control the extra pyramidal effects associated with antipsychotic agents? A. Clorazepate (Tranxene) B. Amantadine (Symmetrel) C. Doxepin (Sinequan) D. Perphenazine (Trilafon)

B. Amantadine is an anticholinergic drug used to relive drug-induced extra pyramidal adverse effects such as muscle weakness, involuntary muscle movements, pseudoparkinsonism and tar dive dyskinesia.

11. In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene? A. Remaining with the client and staying calm B. Calling a security guard and another staff member for assistance C. Telling the client's husband that he must leave at once D. Determining why the husband feels so angry

B. Calling a security guard and another staff member for assistance The health care worker who witnesses this scene must take precautions to ensure personal as well as client safety but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member.

20. When planning care for a client who has ingested phencyclidine (PCP), nurse Wayne is aware that the following is the highest priority? A. Client's physical needs B. Client's safety needs C. Client's psychosocial needs D. Client's medical needs

B. Client's safety needs The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily.

37. A client with depressive symptoms is given prescribed medications and talks with his therapist about his belief that he is worthless and unable to cope with life. Psychiatric care in this treatment plan is based on which framework? A. Behavioral framework B. Cognitive framework C. Interpersonal framework D. Psychodynamic framework

B. Cognitive thinking therapy focuses on the client's misperceptions about self, others and the world that impact functioning and contribute to symptoms. Using medications to alter neurotransmitter activity is a psychobiologic approachto treatment. The other answer choices are frameworks for care, but hey are not applicable to this situation.

49. Nurse Gerry is aware that the defense mechanism commonly used by clients who are alcoholics is: A. Displacement B. Denial C. Projection D. Compensation

B. Denial is a method of resolving conflict or escaping unpleasant realities by ignoring their existence.

6. For a male client with dysthymic disorder, which of the following approaches would the nurse expect to implement? A. ECT B. Psychotherapeutic approach C. Psychoanalysis D. Antidepressant therapy

B. Dysthymia is a less severe, chronic depression diagnosed when a client has had a depressed mood for more days than not over a period of at least 2 years. Client with dysthymic disorder benefit from psychotherapeutic approaches that assist the client in reversing the negative self image, negative feelings about the future.

13. Nurse Mary is assigned to care for a suicidal client. Initially, which is the nurse's highest care priority? A. Assessing the client's home environment and relationships outside the hospital B. Exploring the nurse's own feelings about suicide C. Discussing the future with the client D. Referring the client to a clergyperson to discuss the moral implications of suicide

B. Exploring the nurse's own feelings about suicide The nurse's values, beliefs, and attitudes toward self-destructive behavior influence responses to a suicidal client; such responses set the overall mood for the nurse-client relationship. Therefore, the nurse initially must explore personal feelings about suicide to avoid conveying negative feelings to the client.

36. Which of the following best explains why tricyclic antidepressants are used with caution in elderly patients? A. Central Nervous System effects B. Cardiovascular system effects C. Gastrointestinal system effects D. Serotonin syndrome effects

B. The TCAs affect norepinephrine as well as other neurotransmitters, and thus have significant cardiovascular side effects. Therefore, they are used with caution in elderly clients who may have increased risk factors for cardiac problems because of their age and other medical conditions. The remaining side effects would apply to any client taking a TCA and are not particular to an elderly person.

23. Which of the following would nurse Ronald use as the best measure to determine a client's progress in rehabilitation? A. The way he gets along with his parents B. The number of drug-free days he has C. The kinds of friends he makes D. The amount of responsibility his job entails

B. The best measure to determine a client's progress in rehabilitation is the number of drug- free days he has. The longer the client is free of drugs, the better the prognosis is.

Which of the following behaviors by a client with dependent personality disorder shows the client has made progress toward the goal of increasing problem-solving skills? A. The client is courteous B. The client asks questions C. The client stops acting out D. The client controls emotions

B. The client asks questions

39. A nursing diagnosis for a male client with a diagnosed multiple personality disorder is chronic low self-esteem probably related to childhood abuse. The most appropriate short term client outcome would be: A. Verbalizing the need for anxiety medications B. Recognizing each existing personality C. Engaging in object-oriented activities D. Eliminating defense mechanisms and phobia

B. The client must recognize the existence of the sub personalities so that interpretation can occur.

8. Terry with mania is skipping up and down the hallway practically running into other clients. Which of the following activities would the nurse in charge expect to include in Terry's plan of care? A. Watching TV B. Cleaning dayroom tables C. Leading group activity D. Reading a book

B. The client with mania is very active & needs to have this energy channeled in a constructive task such as cleaning or tidying the room.

7. Joy who has just experienced her second spontaneous abortion expresses anger towards her physician, the hospital and the "rotten nursing care". When assessing the situation, the nurse recognizes that the client may be using the coping mechanism of: A. Projection B. Displacement C. Denial D. Reaction formation

B. The client's anger over the abortion is shifted to the staff and the hospital because she is unable to deal with the abortion at this time.

25. Joey who has a chronic user of cocaine reports that he feels like he has cockroaches crawling under his skin. His arms are red because of scratching. The nurse in charge interprets these findings as possibly indicating which of the following? A. Delusion B. Formication C. Flash back D. Confusion

B. The feeling of bugs crawling under the skin is termed as formication, and is associated with cocaine use.

29. The nursing assistant tells nurse Ronald that the client is not in the dining room for lunch. Nurse Ronald would direct the nursing assistant to do which of the following? A. Tell the client he'll need to wait until supper to eat if he misses lunch B. Invite the client to lunch and accompany him to the dining room C. Inform the client that he has 10 minutes to get to the dining room for lunch D. Take the client a lunch tray and let the client eat in his room

B. The nurse instructs the nursing assistant to invite the client to lunch & accompany him to the dinning room to decrease manipulation, secondary gain, dependency and reinforcement of negative behavior while maintaining the client's worth.

2. Malou is diagnosed with major depression spends majority of the day lying in bed with the sheet pulled over his head. Which of the following approaches by the nurse would be the most therapeutic? A. Question the client until he responds B. Initiate contact with the client frequently C. Sit outside the clients room D. Wait for the client to begin the conversation

B. The nurse should initiate brief, frequent contacts throughout the day to let the client know that he is important to the nurse. This will positively affect the client's self-esteem.

19. Tina with a histrionic personality disorder is melodramatic and responds to others and situations in an exaggerated manner. Nurse Trish would recommend which of the following activities for Tina? A. Baking class B. Role playing C. Scrap book making D. Music group

B. The nurse would use role-playing to teach the client appropriate responses to others and in various situations. This client dramatizes events, drawn attention to self, and is unaware of and does not deal with feelings. The nurse works to help the client clarify true feelings & learn to express them appropriately.

22. When performing a physical examination on a female anxious client, nurse Nelli would expect to find which of the following effects produced by the parasympathetic system? A. Muscle tension B. Hyperactive bowel sounds C. Decreased urine output D. Constipation

B. The parasympathetic nervous system would produce incomplete G.I. motility resulting in hyperactive bowel sounds, possibly leading to diarrhea.

43. Kellan, a high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome? A. The student discusses conflicts over drug use B. The student accepts a referral to a substance abuse counselor C. The student agrees to inform his parents of the problem D. The student reports increased comfort with making choice

B. The student accepts a referral to a substance abuse counselor All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor

18. A male client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. Nurse Gian realizes that these symptoms probably result from: A. Acetate accumulation B. Thiamine deficiency C. Triglyceride buildup. D. A below-normal serum potassium level

B. Thiamine deficiency Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional deficiencies through diet and vitamin supplements, and preventing such residual disabilities as foot and wrist drop.

48. When planning care for a male client using paranoid ideation, nurse Jasmin should realize the importance of: A. Giving the client difficult tasks to provide stimulation B. Providing the client with activities in which success can be achieved C. Removing stress so that the client can relax D. Not placing any demands on the client

B. This will help the client develop self-esteem and reduce the use of paranoid ideation.

50. A male client has approached the nurse asking for advice on how to deal with his alcohol addiction. Nurse Sally should tell the client that the only effective treatment for alcoholism is: A. Psychotherapy B. Total abstinence C. Alcoholics Anonymous (AA) D. Aversion therapy

B. Total abstinence Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain.

47. A client with dysthymic disorder reports to a nurse that his life is hopeless and will never improve in the future. How can the nurse best respond using a cognitive approach? A. Agree with the client's painful feelings B. Challenge the accuracy of the client's belief C. Deny that the situation is hopeless D. Present a cheerful attitude

B. Use of cognitive techniques allows the nurse to help the client recognize that this negative beliefs may be distortions and that, by changing his thinking, he can adopt more positive beliefs that are realistic and hopeful. Agreeing with the client's feelings and presenting a cheerful attitude are not consistent with a cognitive approach and would not be helpful in this situation. Denying the client's feelings is belittling and may convey that the nurse does not understand the depth of the client's distress.

26. Rosana is in the second stage of Alzheimer's disease who appears to be in pain. Which question by Nurse Jenny would best elicit information about the pain? A. "Where is your pain located?" B. "Do you hurt? (pause) "Do you hurt?" C. "Can you describe your pain?" D. "Where do you hurt?"

B. When speaking to a client with Alzheimer's disease, the nurse should use close-ended questions.Those that the client can answer with "yes" or "no" whenever possible and avoid questions that require the client to make choices. Repeating the question aids comprehension.

4. A 48 year old male client is brought to the psychiatric emergency room after attempting to jump off a bridge. The client's wife states that he lost his job several months ago and has been unable to find another job. The primary nursing intervention at this time would be to assess for: A. A past history of depression B. Current plans to commit suicide C. The presence of marital difficulties D. Feelings of excessive failure

B. Whether there is a suicide plan is a criterion when assessing the client's determination to make another attempt.

Benzotropine (Cogentin) is used to treat the extrapyramidal effects induced by antipsychotics. This drug exerts its effects by: A. decreasing the anxiety causing muscle rigidity B. blocking the cholinergic activity on the CNS C. increasing the acetylcholine in the CNS D. increasing norepinephrine in the CNS

B. blocking the cholinergic activity on the CNS

A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be:

Badly stained teeth

The nurse would expect a client with early Alzheimer's disease to have problems with:

Balancing a checkbook

A woman is admitted to the psychiatric emergency department. Her significant other reports that she has difficulty sleeping, has poor judgment, and is incoherent at times. The client's speech is rapid and loose. She reports being a special messenger from the Messiah. She has a history of depressed mood for which she has been taking an antidepressant. The nurse suspects which diagno

Bipolar illness Explanation: Option C: Bipolar illness is characterized by mood swings from profound depression to elation and euphoria. Delusions of grandeur along with pressured speech are common symptoms of mania.

Lorraine, a client diagnosed with somatic symptom disorder, tells the nurse about a pain in her side. She says she has not experienced it before. Which is the most appropriate response by the nurse?

C) "i will report this pain to your physician. in the meantime, group therapy starts in 5 minutes. you must leave now to be on time"

9. When assessing a male client for suicidal risk, which of the following methods of suicide would the nurse identify as most lethal? A. Wrist cutting B. Head banging C. Use of gun D. Aspirin overdose

C. A crucial factor is determining the lethality of a method is the amount of time that occurs between initiating the method & the delivery of the lethal impact of the method.

12. When developing the plan of care for a client receiving haloperidol, which of the following medications would nurse Monet anticipate administering if the client developed extra pyramidal side effects? A. Olanzapine (Zyprexa) B. Paroxetine (Paxil) C. Benztropine mesylate (Cogentin) D. Lorazepam (Ativan)

C. The drug of choice for a client experiencing extra pyramidal side effects from haloperidol (Haldol) is benztropine mesylate (cogentin) because of its anti cholinergic properties.

The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is the most appropriate? A. Approach the client and touch him to get his attention. B. Encourage the client to go to his room where he'll experience fewer distractions. C. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices. D. Ask the client to describe what the voices are saying.

C. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.

50. Within a few hours of alcohol withdrawal, nurse John should assess the male client for the presence of: A. Disorientation, paranoia, tachycardia B. Tremors, fever, profuse diaphoresis C. Irritability, heightened alertness, jerky movements D. Yawning, anxiety, convulsions

C. Alcohol is a central nervous system depressant. These symptoms are the body's neurologic adaptation to the withdrawal of alcohol.

27. Which of the following liquids would nurse Leng administer to a female client who is intoxicated with phencyclidine (PCP) to hasten excretion of the chemical? A. Shake B. Tea C. Cranberry Juice D. Grape juice

C. An acid environment aids in the excretion of PCP. The nurse will definitely give the client with PCP intoxication cranberry juice to acidify the urine to a ph of 5.5 & accelerate excretion.

17. Which statement about an individual with a personality disorder is true? A. Psychotic behavior is common during acute episodes B. Prognosis for recovery is good with therapeutic intervention C. The individual typically remains in the mainstream of society, although he has problems in social and occupational roles D. The individual usually seeks treatment willingly for symptoms that are personally distressful.

C. An individual with personality disorder usually is not hospitalized unless a coexisting Axis I psychiatric disorder is present. Generally, these individuals make marginal adjustments and remain in society, although they typically experience relationship and occupational problems related to their inflexible behaviors. Personality disorders are chronic lifelong patterns of behavior; acute episodes do not occur. Psychotic behavior is usually not common, although it can occur in either schizotypal personality disorder or borderline personality disorder. Because these disorders are enduring and evasive and the individual is inflexible, prognosis for recovery is unfavorable. Generally, the individual does not seek treatment because he does not perceive problems with his own behavior. Distress can occur based on other people's reaction to the individual's behavior.

20. Joy has entered the chemical dependency unit for treatment of alcohol dependency. Which of the following client's possession will the nurse most likely place in a locked area? A. Toothpaste B. Shampoo C. Antiseptic wash D. Moisturizer

C. Antiseptic mouthwash often contains alcohol & should be kept in locked area, unless labeling clearly indicates that the product does not contain alcohol.

16. When planning care for Dory with schizotypal personality disorder, which of the following would help the client become involved with others? A. Attending an activity with the nurse B. Leading a sing a long in the afternoon C. Participating solely in group activities D. Being involved with primarily one to one activities

C. Attending activity with the nurse assists the client to become involved with others slowly. The client with schizotypal personality disorder needs support, kindness & gentle suggestion to improve social skills & interpersonal relationship.

37. A male client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink six (6) hours before admission. Based on this response, nurse Lorena should expect early withdrawal symptoms to: A. Begin after seven (7) days B. Not occur at all because the time period for their occurrence has passed C. Begin anytime within the next one (1) to two (2) days D. Begin within two (2) to seven (7) days

C. Begin anytime within the next one (1) to two (2) days Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Delirium tremens may occur 2 to 4 days — even up to 7 days — after the last drink.

49. The home health psychiatric nurse visits a client with chronic schizophrenia who was recently discharged after a prolong stay in a state hospital. The client lives in a boarding home, reports no family involvement, and has little social interaction. The nurse plan to refer the client to a day treatment program in order to help him with: A. Managing his hallucinations B. Medication teaching C. Social skills training D. Vocational training

C. Day treatment programs provide clients with chronic, persistent mental illness training in social skills, such as meeting and greeting people, asking questions or directions, placing an order in a restaurant, taking turns in a group setting activity. Although management of hallucinations and medication teaching may also be part of the program offered in a day treatment, the nurse is referring the client in this situation because of his need for socialization skills. Vocational training generally takes place in a rehabilitation facility; the client described in this situation would not be a candidate for this service.

Most antipsychotic medications exert which of the following effects on the CNS? A. Stimulate the CNS by blocking post synaptic dopamine, norepinephrine and serotonin receptors. B. Sedates the CNS by stimulating serotonin at the synaptic cleft. C. Depress the CNS by blocking the post synaptic transmission of dopamine, serotonin and norepinephrine D. Depress the CNS by stimulating the release of acetylcholine

C. Depress the CNS by blocking the post synaptic transmission of dopamine, serotonin and norepinephrine

26. A male client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal chest pain. The electrocardiogram (ECG) shows a 1-mm ST-segment elevation the anteroseptal leads and T-wave inversion in leads V3 to V5. Considering the client's history of drug abuse, nurse Greg expects the physician to prescribe: A. Lidocaine (Xylocaine). B. Procainamide (Pronestyl) .C. Nitroglycerin (Nitro-Bid IV). D. Epinephrine.

C. Nitroglycerin (Nitro-Bid IV). The elevated ST segments in this client's ECG indicate myocardial ischemia. To reverse this problem, the physician is most likely to prescribe an infusion of nitroglycerin to dilate the coronary arteries.

11. Nurse John is aware that the therapy that has the highest success rate for people with phobias would be: A. Psychotherapy aimed at rearranging maladaptive thought process B. Psychoanalytical exploration of repressed conflicts of an earlier development phase C. Systematic desensitization using relaxation technique D. Insight therapy to determine the origin of the anxiety and fear

C. The most successful therapy for people with phobias involves behavior modification techniques using desensitization.

41. When asking the parents about the onset of problems in young client with the diagnosis of schizophrenia, Nurse Linda would expect that they would relate the client's difficulties began in: A. Early childhood B. Late childhood C. Adolescence D. Puberty

C. The usual age of onset of schizophrenia is adolescence or early childhood.

43. In recognizing common behaviors exhibited by male client who has a diagnosis of schizophrenia, nurse Josie can anticipate: A. Slumped posture, pessimistic out look and flight of ideas B. Grandiosity, arrogance and distractibility C. Withdrawal, regressed behavior and lack of social skills D. Disorientation, forgetfulness and anxiety

C. These are the classic behaviors exhibited by clients with a diagnosis of schizophrenia.

6. When working with children who have been sexually abused by a family member it is important for the nurse to understand that these victims usually are overwhelmed with feelings of: A. Humiliation B. Confusion C. Self blame D. Hatred

C. These children often have nonsexual needs met by individual and are powerless to refuse.Ambivalence results in self-blame and also guilt.

33. What is the priority care for a client with a dementia resulting from AIDS? A. Planning for remotivational therapy B. Arranging for long term custodial care C. Providing basic intellectual stimulation D. Assessing pain frequently

C. This action maintains for as long as possible, the clients intellectual functions by providing an opportunity to use them.

The nurse is preparing for the discharge of a client who has been hospitalized for paranoid schizophrenia. The client's husband expresses concern over whether his wife will continue to take her daily prescribed medication. The nurse should inform him that: A. his concern is valid but his wife is an adult and has the right to make her own decisions B. he can easily mix the medication in his wife's food if she stops taking it C. his wife can be given a long-acting medication that is administered every 1 to 4 weeks D. his wife knows she must take her medication as prescribed to avoid further hospitalizations

C. his wife can be given a long-acting medication that is administered every 1 to 4 weeks

46. A female client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, nurse Tair should plan to: A. Severely restrict the client's physical activities B. Weigh the client daily, after the evening meal C. Monitor vital signs, serum electrolyte levels, and acid-base balance D. Instruct the client to keep an accurate record of food and fluid intake

C. monitor vital signs, serum electrolyte levels, and acid-base balance An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level, and acid-base balance is crucial.

Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa would be...

Cardiac dysrhythmias resulting to cardiac arrest

Which of the following signs should the nurse expect in a client with known amphetamine overdose?

Tachycardia Explanation: Option B: Amphetamines are central nervous system stimulants. They cause sympathetic stimulation, including hypertension, tachycardia, vasoconstriction, and hyperthermia.

22. A male client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, he sits staring blankly at his bleeding wrists while staff members call for an ambulance. How should Nurse Anuktakanuk approach her initially? A. Enter the room quietly and move beside him to assess his injuries B. Call for staff back-up before entering the room and restraining him C. Move as much glass away from him as possible and sit next to him quietly D. Approach him slowly while speaking in a calm voice, calling him name, and telling him that the nurse is here to help him

D. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her Ensuring the safety of the client and the nurse is the priority at this time. Therefore, the nurse should approach the client cautiously while calling her name and talking to her in a calm, confident manner.

According to the DSM-5 diagnostic criteria for dissociative amnesia (DA), what symptom would be essential to meet the criteria for the subcategory of dissociative fugue?

Clinically significant distress in social and occupational functioning

The nurse correctly teaches a client taking the benzodiazepine oxazepam (Serax) to avoid excessive intake of:

Coffee Explanation: Coffee contains caffeine, which has a stimulating effect on the central nervous system that will counteract the effect of the antianxiety medication oxazepam.

Nurse Penny is aware that the following medical conditions is commonly found in clients with bulimia nervosa?

Diabetes mellitus Explanation: Bulimia nervosa can lead to many complications, including diabetes, heart disease, and hypertension.

Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that this is typical of?

Confabulation

Freud explains anxiety as:

Conflict between id and superego

A nurse is teaching a stress-management program for client. Which of the following beliefs will the nurse advocate as a method of coping with stressful life events?

Control over one's response to stress is possible

During a community visit, volunteer nurses teach stress management to the participants. The nurses will most likely advocate which belief as a method of coping with stressful life events?

Control over one's response to stress is possible

A male client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. Nurse Ryan notes a rise in the client's arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use?

Coronary artery spasm Explanation: Cocaine use may cause such cardiac complications as coronary artery spasm, myocardial infarction, dilated cardiomyopathy, acute heart failure, endocarditis, and sudden death.

A male client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. Nurse Ryan notes a rise in the client's arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use?

Coronary artery spasm Explanation: Cocaine use may cause such cardiac complications as coronary artery spasm, myocardial infarction, dilated cardiomyopathy, acute heart failure, endocarditis, and sudden death. Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of these neurotransmitters at postsynaptic receptor sites. Consequently, the drug is more likely to cause tachyarrhythmias

During which phase of alcoholism is loss of control and physiologic dependence evident?

Crucial phase

46. When being admitted to a mental health facility, a young female adult tells Nurse Mylene that the voices she hears frighten her. Nurse Mylene understands that the client tends to hallucinate more vividly: A. While watching TV B. During meal time C. During group activities D. After going to bed

D. Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions.

24. A female client is brought by ambulance to the hospital emergency room after taking an overdose of barbiturates is comatose. Nurse Trish would be especially alert for which of the following? A. Epilepsy B. Myocardial Infarction C. Renal failure D. Respiratory failure

D. Barbiturates are CNS depressants; the nurse would be especially alert for the possibility of respiratory failure. Respiratory failure is the most likely cause of death from barbiturate over dose.

34. A male client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse Linda, which statement by the client most strongly supports a diagnosis of psychoactive substance abuse? A. "I'm not addicted to alcohol. In fact, I can drink more than I used to without being affected." B. "I only spend half of my paycheck at the bar." C. "I just drink to relax after work." D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me."

D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me." According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, diagnostic criteria for psychoactive substance abuse include a maladaptive pattern of such use, indicated either by continued use despite knowledge of having a persistent or recurrent social, occupational, psychological, or physical problem caused or exacerbated by substance abuse or recurrent use in dangerous situations (for example, while driving).

6. During postprandial monitoring, a female client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you had sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response? A. "I trust you not to purge." B. "How are you purging and when do you do it?" C. "Don't worry. I won't allow you to purge today." D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."

D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat." This response acknowledges that the client is testing limits and that the nurse is setting them by performing postprandial monitoring to prevent self-induced emesis. Clients with bulimia nervosa need to feel in control of the diet because they feel they lack control over all other aspects of their lives.

15. Andy is admitted to the psychiatric unit with a diagnosis of borderline personality disorder. Nurse Hilary should expects the assessment to reveal: A. Coldness, detachment and lack of tender feelings B. Somatic symptoms C. Inability to function as responsible parent D. Unpredictable behavior and intense interpersonal relationships

D. A client with borderline personality displays a pervasive pattern of unpredictable behavior, mood and self image. Interpersonal relationships may be intense and unstable and behavior may be inappropriate and impulsive.

Upon evaluation of the patient's record, the nurse sees the admission was voluntary. Based on this data, the nurse expects which patient behavior? A. Fearfulness regarding treatment measures B. Anger and aggressiveness directed toward others C. An understanding of the pathology and symptoms of the diagnosis D. A willingness to participate in the planning of the care and treatment plan

D. A willingness to participate in the planning of the care and treatment plan

40. A 25 year old male is admitted to a mental health facility because of inappropriate behavior. The client has been hearing voices, responding to imaginary companions and withdrawing to his room for several days at a time. Nurse Monette understands that the withdrawal is a defense against the client's fear of: A. Phobia B. Powerlessness C. Punishment D. Rejection

D. An aloof, detached, withdrawn posture is a means of protecting the self by withdrawing and maintaining a safe, emotional distance.

45. Which nursing diagnosis is most appropriate for a client with anorexia nervosa who expresses feelings of guilt about not meeting family expectations? A. Anxiety B. Disturbed body image C. Defensive coping Powerlessness

D. The client with anorexia typically feels powerless, with a sense of having little control over any aspect of life besides eating behavior. Often, parental expectations and standards are quite high and lead to the clients' sense of guilt over not measuring up.

9. Nurse Trish suggests a crisis intervention group to a client experiencing a developmental crisis. These groups are successful because the: A. Crisis intervention worker is a psychologist and understands behavior patterns B. Crisis group supplies a workable solution to the client's problem C. Client is encouraged to talk about personal problems D. Client is assisted to investigate alternative approaches to solving the identified problem

D. Crisis intervention group helps client reestablish psychologic equilibrium by assisting them to explore new alternatives for coping. It considers realistic situations using rational and flexible problem solving methods.

35. The primary nursing diagnosis for a female client with a medical diagnosis of major depression would be: A. Situational low self-esteem related to altered role B. Powerlessness related to the loss of idealized self C. Spiritual distress related to depression D. Impaired verbal communication related to depression

D. Depressed clients demonstrate decreased communication because of lack of psychic or physical energy.

30. A male adult client voluntarily admits himself to the substance abuse unit. He confesses that he drinks one (1) qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition? A. Vomiting, diarrhea, and bradycardia B. Dehydration, temperature above 101° F (38.3° C), and pruritus C. Hypertension, diaphoresis, and seizures D. Diaphoresis, tremors, and nervousness

D. Diaphoresis, tremors, and nervousness Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability.

21. Nurse Jessie is assessing a client suffering from stress and anxiety. A common physiological response to stress and anxiety is: A. Uticaria B. Vertigo C. Sedation D. Diarrhea

D. Diarrhea is a common physiological response to stress and anxiety.

44. Which of the following is the most distinguishing feature of a client with an antisocial personality disorder? A. Attention to detail and order B. Bizarre mannerisms and thoughts C. Submissive and dependent behavior D. Disregard for social and legal norms

D. Disregard for established rules of society is the most common characteristic of a client with antisocial personality disorder. Attention to detail and order is characteristic of someone with obsessive compulsive disorder. Bizarre mannerisms and thoughts are characteristics of a client with schizoid or schizotypal disorder. Submissive and dependent behaviors are characteristic of someone with a dependent personality.

29. Erlinda, age 85, with major depression undergoes a sixth electroconvulsive therapy (ECT) treatment. When assessing the client immediately after ECT, the nurse expects to find: A. Permanent short-term memory loss and hypertension B. Permanent long-term memory loss and hypomania C. Transitory short-term memory loss and permanent long-term memory loss D. Transitory short and long term memory loss and confusion

D. ECT commonly causes transitory short and long term memory loss and confusion, especially in geriatric clients. It rarely results in permanent short and long term memory loss.

25. Which nursing action is most appropriate when trying to diffuse a client's impending violent behavior? A. Place the client in seclusion B. Leaving the client alone until he can talk about his feelings C. Involving the client in a quiet activity to divert attention D. Helping the client identify and express feelings of anxiety and anger

D. In many instances, the nurse can diffuse impending violence by helping the client identify and express feelings of anger and anxiety. Such statement as "What happened to get you this angry?" may help the client verbalizes feelings rather than act on them

A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The nurse suspects what complication of antipsychotic medication therapy? A. agranulocytosis B. Extrapyramidal effects C. Anticholinergic effects D. Neuroleptic malignant syndrome (NMS)

D. Neuroleptic malignant syndrome (NMS)

31. When monitoring a female client recently admitted for treatment of cocaine addiction, nurse Aaron notes sudden increases in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe: A. Norepinephrine (Levophed) and Lidocaine (Xylocaine) B. Nifedipine (Procardia) and Lidocaine. C. Nitroglycerin (Nitro-Bid IV) and Esmolol (Brevibloc) D. Nifedipine and Esmolol

D. Nifedipine and Esmolol This client requires a vasodilator, such as nifedipine, to treat hypertension, and a beta-adrenergic blocker, such as esmolol, to reduce the heart rate.

13. In the diagnosis of a possible pervasive developmental autistic disorder. The nurse would find it most unusual for a 3 year old child to demonstrate: A. An interest in music B. An attachment to odd objects C. Ritualistic behavior D. Responsiveness to the parents

D. One of the symptoms of autistic child displays a lack of responsiveness to others. There is little or no extension to the external environment.

23. A female client with anorexia nervosa describes herself as "a whale." However, the nurse's assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should nurse Angel be included in the plan of care? A. Asking the client to compare her figure with magazine photographs of women her age B. Assigning the client to group therapy in which participants provide realistic feedback about her weight C. Confronting the client about her actual appearance during one-on-one sessions, scheduled during each shift D. Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy

D. Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health.

When discharging a client after treatment for a dystonic reaction, the emergency department nurse must ensure that the client understands which of the following? A. Results of treatment are rapid and dramatic but may not last B. Although uncomfortable, this reaction isn't serious C. The client shouldn't buy drugs on the street D. The client must take benztropin (Cogentin) as prescribed to prevent a return of symptoms

D. The client must take benztropin (Cogentin) as prescribed to prevent a return of symptoms

3. Joe who is very depressed exhibits psychomotor retardation, a flat affect and apathy. The nurse in charge observes Joe to be in need of grooming and hygiene. Which of the following nursing actions would be most appropriate? A. Waiting until the client's family can participate in the client's care B. Asking the client if he is ready to take shower C. Explaining the importance of hygiene to the client D. Stating to the client that it's time for him to take a shower

D. The client with depression is preoccupied, has decreased energy, and is unable to make decisions. The nurse presents the situation, "It's time for a shower", and assists the client with personal hygiene to preserve his dignity and self-esteem.

18. Nurse John is talking with a client who has been diagnosed with antisocial personality about how to socialize during activities without being seductive. Nurse John would focus the discussion on which of the following areas? A. Discussing his relationship with his mother B. Asking him to explain reasons for his seductive behavior C. Suggesting to apologize to others for his behavior D. Explaining the negative reactions of others toward his behavior

D. The nurse would explain the negative reactions of others towards the client's behaviors to make the clients aware of the impact of his seductive behaviors on others.

26. Jose is diagnosed with amphetamine psychosis and was admitted in the emergency room. Nurse Ronald would most likely prepare to administer which of the following medication? A. Librium B. Valium C. Ativan D. Haldol

D. The nurse would prepare to administer an antipsychotic medication such as Haldol to a client experiencing amphetamine psychosis to decrease agitation & psychotic symptoms, including delusions, hallucinations & cognitive impairment.

10. Jun has been hospitalized for major depression and suicidal ideation. Which of the following statements indicates to the nurse that the client is improving? A. "I'm of no use to anyone anymore." B. "I know my kids don't need me anymore since they're grown." C. "I couldn't kill myself because I don't want to go to hell." D. "I don't think about killing myself as much as I used to."

D. The statement "I don't think about killing myself as much as I used to." Indicates a lessening of suicidal ideation and improvement in the client's condition.

3. A tentative diagnosis of opiate addiction, Nurse Candy should assess a recently hospitalized client for signs of opiate withdrawal. These signs would include: A. Rhinorrhea, convulsions, subnormal temperature B. Nausea, dilated pupils, constipation C. Lacrimation, vomiting, drowsiness D. Muscle aches, papillary constriction, yawning

D. These adaptations are associated with opiate withdrawal which occurs after cessation or reduction of prolonged moderate or heavy use of opiates.

Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, "Do you know why people find you repulsive?" this statement most likely would elicit which of the following client reaction?

Defensiveness Explanation: Option A: When the staff member ask the client if he wonders why others find him repulsive, the client is likely to feel defensive because the question is belittling. The natural tendency is to counterattack the threat to self image.

A man is admitted to the nursing care unit with a diagnosis of cirrhosis. He has a long history of alcohol dependence. During the late evening following his admission, he becomes increasingly disoriented and agitated. Which of the following would the client be least likely to experience?

Delusions of grandeu

A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but he can control his use if he chooses. Which coping mechanism is he using?

Denial

In group therapy, a client who has used I.V. heroin every day for the past 14 years says, "I don't have a drug problem. I can quit whenever I want. I've done it before." Which defense mechanism is the client using?

Denial

The nurse understands that electroconvulsive therapy is primary used in psychiatric care for the treatment of:

Depression Explanation: Electroconvulsive therapy (ECT) can provide relief for patients with severe depression who have not been able to feel better with other treatments. In some severe cases where rapid response is necessary or medications cannot be used safely, ECT can even be a first-line intervention. ECT consists of a series of sessions, typically three times a week, for two to four wee

A client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition?

Diaphoresis, tremors, and nervousness

A male adult client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition?

Diaphoresis, tremors, and nervousness Explanation: Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability.

A client taking the MAOI phenelzine (Nardil) tells the nurse that he routinely takes all of the medications listed below. Which medication would cause the nurse to express concern and therefore initiate further teaching?

Diphenhydramine (Benadryl) Explanation: Over-the-counter medications used for allergies and cold symptoms are contraindicated because they will increase the sympathomimetic effects of MAOIs, possibly causing a hypertensive crisis.

Conney with borderline personality disorder who is to be discharged soon threatens to "do something" to herself if discharged. Which of the following actions by the nurse would be most important?

Discuss the meaning of the client's statement with her Explanation: Option B: Any suicidal statement must be assessed by the nurse. The nurse should discuss the client's statement with her to determine its meaning in terms of suicide.

In the management of bulimic patients, the following nursing interventions will promote a therapeutic relationship EXCEPT: A.Establish an atmosphere of trust B.Discuss their eating behavior. C.Help patients identify feelings associated with binge-purge behavior D. Teach patient about bulimia nervosa

Discuss their eating behavior. Explanation: The client is often ashamed of her eating behavior.

The nurse is teaching a group of clients about the mood-stabilizing medications lithium carbonate. Which medications should she instruct the clients to avoid because of the increased risk of lithium toxicity?`

Diuretics Explanation: The use of diuretics would cause sodium and water excretion, which would increase the risk of lithium toxicity. Clients taking lithium carbonate should be taught to increase their fluid intake and to maintain normal intake of sodium.

A 45-year-old woman with a history of depression tells a nurse in her doctor's office that she has difficulty with sexual arousal and is fearful that her husband will have an affair. Which of the following factors would the nurse identify as least significant in contributing to the client's sexual difficulty?

Education and work history Age, health status, physical attributes and relationship issues have great influence on sexual expression.

A 32-year-old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate:

Effective self-boundaries

Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed?

Electroconvulsive therapy Electroconvulsive therapy is an effective treatment for depression that has not responded to medication.

A 16-year-old girl has returned home following hospitalization for treatment of anorexia nervosa. The parents tell the family nurse performing a home visit that their child has always done everything to please them and they cannot understand her current stubbornness about eating. The nurse analyzes the family situation and determines it is characteristic of which relationship style?

Enmeshment Explanation: Enmeshment is a fusion or over involvement among family members whereby the expectation exists that all members think and act alike. The child who always acts to please her parents is an example of how enmeshment affects development in many cases, a child who develops anorexia nervosa exerts control only in the area of eating behavior.

The emergency department nurse is assigned to provide care for a victim of a sexual assault. When following legal and agency guidelines, which intervention is most important?

Ensure an unbroken chain of evidence. Question 18 Explanation: Establishing an unbroken chain of evidence is essential in order to ensure that the prosecution of the perpetrator can occur. The nurse will also need to preserve the client's privacy and identify the extent of injury. However, it is essential that the nurse follow legal and agency guidelines for preserving evidence. Identifying the assailant is the job of law enforcement, not the nurse.

The nurse formulates a nursing diagnosis of Impaired verbal communication for a client with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention is most appropriate?

Establishing a one-on-one relationship with the client

Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the client is holding his head to one side and complaining of neck and jaw spasms. What should the nurse do?

Evaluate the client for adverse reactions to haloperidol

The parents of a young man with schizophrenia express feelings of responsibility and guilt for their son's problems. How can the nurse best educate the family?

Explain the biological nature of schizophrenia Explanation: The parents are feeling responsible and this inappropriate self-blame can be limited by supplying them with the facts about the biologic basis of schizophrenia.

A 45-year-old woman with a history of depression tells a nurse in her doctor's office that she has difficulty with sexual arousal and is fearful that her husband will have an affair. Which of the following factors would the nurse identify as least significant in contributing to the client's sexual difficulty?

Explanation: Education and work history would have the least significance in relation to the client's sexual problem. Age, health status, physical attributes and relationship issues have great influence on sexual expression.

Nurse Mary is assigned to care for a suicidal client. Initially, which is the nurse's highest care priority?

Exploring the nurse's own feelings about suicide

The following statements describe somatoform disorders:

Expression of conflicts through bodily symptoms

A long-term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop:

Feeling of self-worth

Nurse Tony was caring for a 41-year-old female client. Which behavior by the client indicates adult cognitive development?

Generates new levels of awareness

Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is known as:

Hallucinations Explanation: Option A: Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no basis in reality.

Which of the following is important when restraining a violent client?

Have an organized, efficient team approach after the decision is made to restrain the client.

Nurse Bella is aware that assessment finding is most consistent with early alcohol withdrawal?

Heart rate of 120 to 140 beats/minutes

Which nursing intervention is most appropriate for a client with anorexia nervosa during initial hospitalization on a behavioral therapy unit?

Help establish a plan using privileges and restrictions based on compliance with refeeding. Explanation: Inpatient treatment of a client with anorexia usually focuses initially on establishing a plan for refeeding to combat the effects of self-induced starvation. Refeeding is accomplished through behavioral therapy, which uses a system of rewards and reinforcements to assist in establishing weight restoration. Emphasizing nutrition and teaching the client about the long-term physical consequences of anorexia maybe appropriate at a later time in the treatment program. The nurse needs to assess the client's mealtime behavior continually to evaluate treatment effectiveness.

The nurse provides a referral to Alcoholics Anonymous to a client who describes a 20-year history of alcohol abuse. The primary function of this group is to:

Help members maintain sobriety. Explanation: The primary purpose of Alcoholics Anonymous is to help members achieve and maintain sobriety

Which nursing action is best when trying to diffuse a client's impending violent behavior?

Helping the client identify and express feelings of anxiety and anger

To further assess a client's suicidal potential. Nurse Katrina should be especially alert to the client expression of:

Helplessness & hopelessness

When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the ritual:

Helps the client control the anxiety

The nurse understands that if a client continues to be dependent on heroin throughout her pregnancy, her baby will be at high risk for:

Heroin dependence. Explanation: Babies born to heroin-dependent women are also heroin-dependent and need to go through withdrawal. There is no evidence to support any of the remaining answer choices.

A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is:

Highly famous and important Explanation: Option B: Delusion of grandeur is a false belief that one is highly famous and important.

Charina, a college student who frequently visited the health center during the past year with multiple vague complaints of GI symptoms before course examinations. Although physical causes have been eliminated, the student continues to express her belief that she has a serious illness. These symptoms are typically of which of the following disorders?

Hypochondriasis

Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is?

Identify anxiety causing situations Explanation: Option B: Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.

A 20-year-old client was diagnosed with dependent personality disorder. Which behavior is not most likely to be evidence of ineffective individual coping?

Inability to make choices and decision without advise Explanation: Option D: Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them.

A client with schizophrenia is receiving antipsychotic medication. Which nursing diagnosis may be appropriate for this client?

Ineffective protection related to blood dyscrasias Explanation: Option A: Antipsychotic medications may cause neutropenia and granulocytopenia, life-threatening blood dyscrasias, that warrant a nursing diagnosis of Ineffective protection related to blood dyscrasias. These medications also have anticholinergic effects, such as urine retention, dry mouth, and constipation.

A severely dehydrated teenager admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. Her history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the last month. She is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority?

Initiating caloric and nutritional therapy as ordered

Two nurses are co-leading group therapy for seven clients in the psychiatric unit. The leaders observe that the group members are anxious and look to the leaders for answers. Which phase of development is this group in?

Initiation phase

A client is admitted to the psychiatric unit with a diagnosis of alcohol intoxication and suspected alcohol dependence. Other assessment findings include an enlarged liver, jaundice, lethargy, and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what is the first priority?

Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output

A client tells the nurse that he is having suicidal thoughts every day. In conferring with the treatment team, the nurse should make which of the following recommendations?

Intensive inpatient treatment

An unemployed woman, age 24, seeks help because she feels depressed and abandoned and doesn't know what to do with her life. She says she has quit her last five jobs because her coworkers didn't like her and didn't train her adequately. Last week, her boyfriend broke up with her after she drove his car into a tree after an argument. The client's initial diagnosis is borderline personality disorder. Which nursing observations support this diagnosis?

Lack of self-esteem, strong dependency needs, and impulsive behavior

Nurse Mary is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important?

Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal Question 12 Explanation: Allowing the client to select her own food from the menu will help her feel some sense of control. She must then eat 100% of what she selected. Remaining with the client for at least 1 hour after eating will prevent purging. Bulimic clients should only be allowed to eat food provided by the dietary department.

A 23-year-old client has been admitted with a diagnosis of schizophrenia says to the nurse "Yes, its march, March is little woman". That's literal you know". These statements illustrate:

Loosening of association

Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis, and hyperactivity. Blood pressure is 190/87 mmHg and pulse is 92 bpm. Which of the medications would the nurse expect to administer?

Lorazepam (Ativan)

Clonidine (Catapres) can be used to treat conditions other than hypertension. Nurse Sally is aware that the following conditions might the drug be administered?

Opiate Withdrawal EXPLANATION: Clonidine (Catapres) can be used to treat conditions other than hypertension. Nurse Sally is aware that the following conditions might the drug be administered?

The nurse enters the room of a client with a cognitive impairment disorder and asks what day of the week it is: what the date, month, and year are; and where the client is. The nurse is attempting to assess:

Orientation

A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation?

Paranoid thoughts Explanation: Option A: Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts.

When providing family therapy, the nurse analyzes the functioning of healthy family systems. Which situations would not increase stress on a healthy family system?

Parental disagreement

A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in control of eating habits. The goal for this problem i

Patient will learn problem solving skills

A client with bipolar disorder, manic type, exhibits extreme excitement, delusional thinking, and command hallucinations. Which of the following is the priority nursing diagnosis?

Risk for other-directed violence Question 14 Explanation: A client with these symptoms would have poor impulse control and would therefore be prone to acting-out behavior that may be harmful to either himself or others

An 11-year-old child diagnosed with conduct disorder is admitted to the psychiatric unit for treatment. Which of the following behaviors would the nurse assess?

Physical aggressiveness, low stress tolerance disregard for the rights of others

Odette, a nurse who works at Nurseslabs Rehabilitation Center is assessing a client for recent stressful life events. She recognizes that stressful life events are both:

Positive and negative

For a female client with anorexia nervosa, nurse Rose plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa?

They tend to overprotect their children

A 24-year old client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and feelings?

Provide objective data and feedback regarding the client's weight and attractiveness By focusing on reality, this strategy may help the client develop a more realistic body image and gain self-esteem.

A client begins to experience alcoholic hallucinosis. What is the best nursing intervention at this time?

Providing a quiet environment and administering medication as needed and prescribed

A female client begins to experience alcoholic hallucinosis. Nurse Joy is aware that the best nursing intervention at this time?

Providing a quiet environment and administering medication as needed and prescribed Explanation: Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing oversedation.

Mr. Peterson, 35, is admitted for bipolar illness, manic phase, after assaulting his landlord in an argument over Mr. Peterson is staying up all night playing loud music. Mr. Peterson is hyperactive, intrusive, and has rapid, pressured speech. He has not slept in three days and appears thin and disheveled. Which of the following is the most essential nursing action at this time?

Providing for client safety by limiting his privileges Explanation: Food and fluids are necessary. However, Mr. Peterson's hyperactivity does not allow him to sit quietly to eat. Finger foods "on the run" will provide needed nourishment.

Nurse Helen is assigned to care for a client with anorexia nervosa. Initially, which nursing intervention is most appropriate for this client?

Providing one-on-one supervision during meals and for 1 hour afterward Explanation: Because the client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 hour afterward

The nurse explains to a mental health care technician that a client's obsessive-compulsive behaviors are related to unconscious conflict between id impulses and the superego (or conscience). On which of the following theories does the nurse base this statement?

Psychoanalytic theory Explanation: Psychoanalytic is based on Freud's beliefs regarding the importance of unconscious motivation for behavior and the role of the id and superego in opposition to each other.

The nurse explains to a mental health care technician that a client's obsessive-compulsive behaviors are related to unconscious conflict between id impulses and the superego (or conscience). On which of the following theories does the nurse base this statement?

Psychoanalytic theory Question 2 Explanation: Psychoanalytic is based on Freud's beliefs regarding the importance of unconscious motivation for behavior and the role of the id and superego in opposition to each other.

An agitated and incoherent client, age 29, comes to the emergency department with complaints of visual and auditory hallucinations. The history reveals that the client was hospitalized for paranoid schizophrenia from ages 20 to 21. The physician prescribes haloperidol (Haldol), 5 mg I.M. The nurse understands that this drug is used for this client to treat:

Psychosis

Which method would a nurse use to determine a client's potential risk for suicide?

Question the client directly about suicidal thoughts

Which method would a nurse use to determine a client's potential risk for suicide?

Question the client directly about suicidal thoughts Explanation: Directly questioning a client about suicide is important to determine suicide risk. The client may not bring up this subject for several reasons, including guilt regarding suicide, wishing not to be discovered, and his lack of trust in staff.

A client who abuses alcohol and cocaine tells a nurse that he only uses substances because of his stressful marriage and difficult job. Which defense mechanisms is this client using?

Rationalization Explanation: Rationalization is the defense mechanism that involves offering excuses for maladaptive behavior. The client is defending his substance abuse by providing reasons related to life stressors. This is a common defense mechanism used by clients with substance abuse problems.

Nurse Penny is aware that the symptoms that distinguish post-traumatic stress disorder from other anxiety disorder would be:

Re-experiencing the trauma in dreams or flashback

Which nursing intervention is most appropriate for a client with Alzheimer's disease who has frequent episodes emotional lability?

Reduce environmental stimuli to redirect the client's attention. Explanation: The client with Alzheimer's disease can have frequent episode of labile mood, which can best be handled by decreasing a stimulating environment and redirecting the client's attention.

Mike is admitted to a psychiatric unit with a diagnosis of undifferentiated schizophrenia. Which of the following defense mechanisms is probably used by Mike?

Regression

Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal?

Regular Coffee Explanation: Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. Serving coffee top the client may add to tremors or wakefulness.

Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)?

Report a sore throat or fever to the physician immediately

The nurse is administering a psychotropic drug to an elderly client who has history of benign prostatic hypertrophy. It is most important for the nurse to teach this client to:

Report incomplete bladder emptying Urinary retention is a common anticholinergic side effect of psychotic medications, and the client with benign prostatic hypertrophy would have increased risk for this problem.

A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on this finding, the nurse Lenny should formulate a nursing diagnosis of:

Risk for violence: Self-directed related to impulsive mutilating acts

Prior to administering chlorpromazine (Thorazine) to an agitated client, the nurse should:

Take the client's blood pressure Explanation: Because chlorpromazine (Thorazine) can cause a significant hypotensive effect (and possible client injury), the nurse must assess the client's blood pressure (lying, sitting, and standing) before administering this drug.

To establish an open and trusting relationship with a female client who has been hospitalized with severe anxiety, the nurse in charge should?

Respect client's need for personal space

A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should carefully observe the client for...

Respiratory difficulties Explanation: Option A: Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles.

A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on this finding, the nurse Lenny should formulate a nursing diagnosis of:

Risk for violence: Self-directed related to impulsive mutilating acts Explanation: The predominant behavioral characteristic of the client with borderline personality disorder is impulsiveness, especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn't substantiate the other options.

Hormonal effects of the antipsychotic medications include which of the following?

Retrograde ejaculation and gynecomastia

The nurse considers a client's response to crisis intervention successful if the client:

Returns to his previous level of functioning. Explanation: Crisis intervention is based on the idea that a crisis is a disturbance in homeostasis (steady state). The goal is to help the client return to a previous level of equilibrium in functioning.

The nurse develops a countertransference reaction. This is evidenced by:

Revealing personal information to the client Explanation: Countertransference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts

The nurse is caring for a severely depressed client who has just been admitted to the in-client psychiatric unit. Which of the following is a PRIORITY of care?

Safety

Nurse Monette is aware that extremely depressed clients seem to do best in settings where they have:

Routine Activities Explanation: Option B: Depression usually is both emotional & physical. A simple daily routine is the best, least stressful and least anxiety producing.

Nurse Harry is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?

Set up a strict eating plan for the client Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals — not given privacy. Exercise must be limited and supervised.

Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan?

Set-up a strict eating plan for the client Explanation: Option B: Establishing a consistent eating plan and monitoring client's weight are important to this disorder.

Mario is complaining to other clients about not being allowed by staff to keep food in his room. Which of the following interventions would be most appropriate?

Setting limits on the behavior Explanation: The nurse needs to set limits on the client's manipulative behavior to help the client control dysfunctional behavior. A consistent approach by the staff is necessary to decrease manipulation.

Which of the following will the nurse use when communicating with a client who has a cognitive impairment?

Short words and simple sentences

A client with paranoid thoughts refuses to eat because he believes the food is poisoned. The MOST appropriate initial action is to

Simply state the food is not poisoned

Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the client's room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should...

Sit beside the client in silence and occasionally ask open-ended question

A 30-year-old male employee frequently complains of low back pain that leads to frequent absences from work. Consultation and tests reveal negative results. The client has which somatoform disorder?

Somatoform Pain Disorder

A client is experiencing anxiety attack. The most appropriate nursing intervention should include?

Staying with the client and speaking in short sentences

When teaching the family of a client with schizophrenia, the nurse should provide which information?

Support is available to help family members meet their own needs.

Which of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist?

Supportive confrontation Explanation: Option B: The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self.

A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom?

Tardive dyskinesia

Primary level of prevention is exemplified by:

Teaching the client stress management techniques Explanation: Primary level of prevention refers to the promotion of mental health and prevention of mental illness. T

A female client with anorexia nervosa describes herself as "a whale." However, the nurse's assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should nurse Angel be included in the plan of care?

Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy Explanation: A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health

A female client with anorexia nervosa describes herself as "a whale." However, the nurse's assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should nurse Angel be included in the plan of care?

Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy Explanation: A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health. Instead of protecting the client's health, options A, B, and C may serve to make the client defensive and more entrenched in her unrealistic body image.

A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused?

The child doesn't cry when the shoulder is examined

Which client outcome is most appropriately achieved in a community approach setting in psychiatric nursing?

The client demonstrates self-reliance and social adaptation Explanation: A therapeutic community is designed to help individuals assume responsibility for themselves, to learn how to respect and communicate with others, and to interact in a positive manner.

When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation?

The client identifies anxiety-producing situations

A client with a bipolar disorder exhibits manic behavior. The nursing diagnosis is Disturbed thought processes related to difficulty concentrating, secondary to flight of ideas. Which of the following outcome criteria would indicate improvement in the client?

The client speaks in coherent sentences. Question 10 Explanation: A client exhibiting flight of ideas typically has a continuous speech flow and jumps from one topic to another. Speaking in coherent sentences is an indicator that the client's concentration has improved and his thoughts are no longer racing.

The nurse is caring for a client with schizophrenia. Which of the following outcomes is the least desirable?

The client spends more time by himself

Which is the desired outcome in conducting desensitization:

The client will be able to overcome his disabling fear Explanation: The client will overcome his disabling fear by gradual exposure to the feared object

A nurse is working with a client who has schizophrenia, paranoid type. Which of the following outcomes related to the client's delusional perceptions would the nurse establish?

The client will demonstrate realistic interpretation of daily events in the unit. Explanation: A client with schizophrenia, paranoid type, has distorted perceptions and views people, institutions, and aspects of the environment as plotting against him. The desired outcome for someone with delusional perceptions would be to have a realistic interpretation of daily events

A nurse is working with a client who has schizophrenia, paranoid type. Which of the following outcomes related to the client's delusional perceptions would the nurse establish?

The client will demonstrate realistic interpretation of daily events in the unit. Explanation: A client with schizophrenia, paranoid type, has distorted perceptions and views people, institutions, and aspects of the environment as plotting against him. The desired outcome for someone with delusional perceptions would be to have a realistic interpretation of daily events.

For a female client with anorexia nervosa, Nurse Jimmy is aware that which goal takes the highest priority?

The client will establish adequate daily nutritional intake

The nurse is working with a client with a somatoform disorder. Which client outcome goal would the nurse most likely establish in this situation?

The client will express anxiety verbally rather than through physical symptoms. Explanation: The client with a somatoform disorder displaces anxiety onto physical symptoms. The ability to express anxiety verbally indicates a positive change toward improved health. The remaining responses do not indicate any positive change toward increased coping with anxiety.

Which of the following outcome criteria is appropriate for the client with dementia?

The client will follow an establishing schedule for activities of daily living.

A 25 -year old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority?

The client will work with the nurse to remain safe EXPLANATION: The priority goal in alcohol withdrawal is maintaining the client's safety. Committing to a drug-free lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensuring the client's safety is the nurse's top priority.

A 25 -year old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority?

The client will work with the nurse to remain safe Explanation: The priority goal in alcohol withdrawal is maintaining the client's safety. Committing to a drug-free lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensuring the client's safety is the nurse's top priority.

A client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority?

The client will work with the nurse to remain safe.

Which factors are most essential for the nurse to assess when providing crisis intervention foe a client?

The client's perception of the triggering event and availability of situational supports Explanation: The most important factors to determine in this situations are the client's perception of the crisis event and the availability of support (including family and friends) to provide basic needs.

A 20 year old college student is admitted to the medical ward because of sudden onset of paralysis of both legs. Extensive examination revealed no physical basis for the complaint. The nurse plans intervention based on which correct statement about conversion disorder?

The conversion symptom has symbolic meaning to the client.

Which information is most essential in the initial teaching session for the family of a young adult recently diagnosed with schizophrenia?

The distressing symptoms of this disorder can respond to treatment with medications. Question 12 Explanation: This statement provides accurate information and an element of hope for the family of a schizophrenic client. Although the remaining statements are true, they do not provide the empathic response the family needs after just learning about the diagnosis. These facts can become part of the ongoing teaching.

Which factor is least important in the decision regarding whether a victim of family violence can safely remain in the home?

The family's socioeconomic status

The nurse is teaching a psychiatric client about her prescribed drugs, chlorpromazine and benztropine. Why is benztropine administered?

To reduce extrapyramidal symptoms

Marco approached Nurse Trisha asking for advice on how to deal with his alcohol addiction. Nurse Trisha should tell the client that the only effective treatment for alcoholism is:

Total abstinence

Important teaching for clients receiving antipsychotic medication such as haloperidol (Haldol) includes which of the following instructions?

Use sunscreen because of photosensitivity. Take the antipsychotic medication with food

Which nursing intervention is best for facilitating communication with a psychiatric client who speaks a foreign language?

Use the services of an interpreter

A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner?

Using open-ended question and silence

A patient experiencing disturbed thought processes believes that his food is has been poisoned. Which communication technique should they use to encourage the patient to eat?

Using open-ended questions and silence.

The client with anorexia nervosa is improving if:

Weight gain Explanation: Weight gain is the best indication of the client's improvement. The goal is for the client to gain 1-2 pounds per week.

A male client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal chest pain. The electrocardiogram (ECG) shows a 1-mm ST-segment elevation the anteroseptal leads and T-wave inversion in leads V3 to V5. Considering the client's history of drug abuse, nurse Greg expects the physician to prescribe:

nitroglycerin (Nitro-Bid IV

The nurse is assessing a 17-year-old female who is admitted to the eating disorders unit with a history of weight fluctuation, abdominal pain, teeth erosion, receding gums, and bad breath. She states that her health has been a problem but there are no other concerns in her life. Which of the following assessments will be the least useful as the nurse develops the care plan?

Whether she has a sexual relationship with a boyfriend

Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to alleviate Linda's anxiety. The most therapeutic question by the nurse would be?

Would you like me to talk with you?

What outcome would the nurse expect after providing an appropriate intervention to a client with somatic symptom disorder?

a.The client effectively uses adaptive coping strategies during stressful situations without resorting to physical symptoms.

What is the purpose of prescribing amobarbital to a client with dissociative identity disorder?

a.This medication helps the client remember forgotten events.

What are the symptoms that can be observed in the client diagnosed with depersonalization?

a.Unreality, detachment, and distorted sense of time

Which of the following drugs should Nurse Mary prepare to administer to a client with a toxic acetaminophen (Tylenol) level?

acetylcysteine (Mucomyst)

An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function. The daughter revealed that the client used her toothbrush to comb her hair. She is manifesting:

agnosia Explanation: This is the inability to recognize objects.

Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. Nurse Melinda should suspect:

alcohol withdrawl

A client receiving fluphenazine decanoate (Prolixin Decanoate) therapy develops pseudoparkinsonism. The physician is likely to prescribe which drug to control this extrapyramidal effect?

amantadine (Symmetrel) Explanation: Option B: An antiparkinsonian agent, such as amantadine, may be used to control pseudoparkinsonism;

A client is admitted to the emergency department after being found unconscious. Her blood pressure is 82/50 mm Hg. She is 5′ 4″ (1.6 m) tall, weighs 79 lb (35.8 kg), and appears dehydrated and emaciated. After regaining consciousness, she reports that she has had trouble eating lately and can't remember what she ate in the last 24 hours. She also states that she has had amenorrhea for the past year. She is convinced she is fat and refuses food. The nurse suspects that she has:

anorexia nervosa.

Kevin is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with:

antisocial

On discharge after treatment for alcoholism, a client plans to take disulfiram (Antabuse) as prescribed. When teaching the client about this drug, the nurse emphasizes the need to:

avoid all products containing alcohol

A male client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, nurse Lorena should expect early withdrawal symptoms to:

begin anytime within the next 1 to 2 days Explanation: Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later.

A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to:

begin anytime within the next 1 to 2 days.

A client with schizophrenia who receives fluphenazine (Prolixin) develops pseudoparkinsonism and akinesia. What drug would the nurse administer to minimize extrapyramidal symptoms?

benztropine (Cogentin) Benztropine is an anticholinergic drug administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. It works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS).

Which behavior by the client causes the nurse to suspect ineffective coping?

c.Feigning of physical symptoms to gain attention

An elderly man is admitted to the hospital. He was alert and oriented during the admission interview. However, his family states that he becomes disruptive and disoriented around dinnertime. One night he was shouting furiously and didn't know where he was. He was sedated and the next morning he was fine. At dinnertime the disruptive behavior returned. The client is diagnosed as having sundown syndrome. The client's son asks the nurse what causes sundown syndrome. The nurse's best response is that it is attributed to

changes in the sensory environment.

A female client who's at high risk for suicide needs close supervision. To best ensure the client's safety, Nurse Mary should:

check the client frequently at irregular intervals throughout the night

A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is Nurse Alice most likely to administer to reduce the symptoms of alcohol withdrawal?

chlordiazepoxide (Librium) Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal.

A 35 year old male has intense fear of riding an elevator. He claims " As if I will die inside." This has affected his studies The client is suffering from:

claustrophobia

Another client is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum.

cocaine

The client admitted for alcohol detoxification develops increased tremors, irritability, hypertension and fever. The nurse should be alert for impending:

delirium tremens Explanation: Delirium Tremens is the most extreme central nervous system irritability due to withdrawal from alcohol

The nurse is planning care for a client who has a phobic disorder manifested by a fear of elevators. Which goal would need to be accomplished first? The client

demonstrates the relaxation response when asked. Explanation: The ability to use relaxation is basic to treatment of phobia. Clients with phobias are resistant to insight therapy.

When a husband takes out his work frustrations and anger by abusing his wife at home, the nurse would identify this crisis as which type?

dispositional crisis Explanation: A dispositional crisis is a response to an external situational crisis. External anger at work is the dispositional crisis displaced to his wife through abuse.

A client is admitted to the psychiatric unit with active psychosis. The physician diagnoses schizophrenia after ruling out several other conditions. Schizophrenia is characterized by:

disturbances in affect, perception, and thought content and form.

The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates such as morphine include:

euphoria and constricted pupils.

A 17-year-old gymnast is admitted to the hospital due to weight loss and dehydration secondary to starvation. Which of the following nursing diagnoses will be given priority for the client?

fluid volume deficit Explanation: Fluid volume deficit is the priority over altered nutrition

A client whose husband just left her has a recurrence of anorexia nervosa. Nurse Vic caring for her realizes that this exacerbation of anorexia nervosa results from the client's effort to:

gain control of one part of her life Explanation: By refusing to eat, a client with anorexia nervosa is unconsciously attempting to gain control over the only part of her life she feels she can control.

The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:

hallucinations

What medication would probably be ordered for the acutely aggressive schizophrenic client? A. chlorpromazine (Thorazine) B. haloperidol (Haldol) C. lithium carbonate (Lithonate) D. amitriptyline (Elavil)

haloperidol (Haldol)

Nurse Fey is aware that the drug of choice for treating Tourette syndrome?

haloperidol (Haldol) Explanation: Haloperidol is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil are antidepressants and aren't used to treat Tourette syndrome

Macoy and Helen seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. When intervening with this couple, nurse Gerry knows they are at risk for repeated violence because the husband:

has learned violence as an acceptable behavior

The characteristic manifestation that will differentiate bulimia nervosa from anorexia nervosa is that bulimic individuals

have episodic binge eating and purging Explanation: Bulimia is characterized by binge eating which is characterized by taking in a large amount of food over a short period of time.

A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is:

highly important or famous

During a group therapy session in the psychiatric unit, a client constantly interrupts with impulsive behavior and exaggerated stories that cast her as a hero or princess. She also manipulates the group with attention-seeking behaviors, such as sexual comments and angry outbursts. The nurse realizes that these behaviors are typical of:

histrionic personality disorder.

Nurse Tamara is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:

identify anxiety-causing situations

A 34-year-old woman is admitted for treatment of depression. Which of these symptoms would the nurse be least likely to find in the initial assessment?

increased interest in sex

Dementia unlike delirium is characterized by:

insidious onset Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. A,C and D (slurred speech, clouding, sensory perception change) are all characteristics of delirium.

The ultimate goal of therapy for a client with DID is

integration of the personalities into one

A male client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, Dr. Smith is most likely to prescribe which drug?

lorazepam (Ativan) Explanation: The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Clozapine and thiothixene are antipsychotic agents, and lithium carbonate is an antimanic agent; these drugs aren't used to manage alcohol withdrawal syndrome.

A client is admitted to the inpatient adolescent unit after being arrested for attempting to sell cocaine to an undercover police officer. The nurse plans to write a behavioral contract. To best promote compliance, the contract should be written:

jointly by the client and nurse.

Nurse Anna can minimize agitation in a disturbed client by:

limiting unnecessary interaction

The nurse is providing care for a client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:

methadone

A female client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, nurse Tair should plan to:

monitor vital signs, serum electrolyte levels, and acid-base balance Explanation: An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level, and acid base balance is crucial

A female client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, nurse Tair should plan to:

monitor vital signs, serum electrolyte levels, and acid-base balance Explanation: An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level, and acid base balance is crucial.

When monitoring a client recently admitted for treatment of cocaine addiction, the nurse notes sudden increases in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe:

nifedipine and esmolol

When monitoring a female client recently admitted for treatment of cocaine addiction, nurse Aaron notes sudden increases in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe:

nifedipine and esmolol

Important teaching for a client receiving risperidone (Risperdal) would include advising the client to:

notify the physician if the client notices an increase in bruising

The nurse is discussing electroconvulsive therapy (ECT) with a client who asks how long it will be before she feels better. The nurse explains that the beneficial effects of ECT usually occur within

one week

The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client:

remains in a safe and secure environment

Which of the following ego defense mechanisms describes the underlying psychodynamics of somatic symptom disorder?

repression of anxiety

Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam (Serax). Before administering the medication, nurse Gina should be prepared for which common adverse effect?

seizures

How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client's delusional thoughts and hallucinations eliminated?

several weeks

A male client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. Nurse Gian realizes that these symptoms probably result from:

thiamine deficiency Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake.

A client with paranoid schizophrenia is admitted to the psychiatric unit of a hospital. Nursing assessment should include careful observation of the client's:

thinking, perceiving, and decision-making skills

The nurse assigned in the detoxification unit attends to various patients with substance-related disorders. A 45 years old male revealed that he experienced a marked increase in his intake of alcohol to achieve the desired effect This indicates:

tolerance Explanation: tolerance refers to the increase in the amount of the substance to achieve the same effects. A. Withdrawal refers to the physical signs and symptoms that occur when the addictive substance is reduced or withheld. B. Intoxication refers to the behavioral changes that occur upon recent ingestion of a substance. D. Psychological dependence refers to the intake of the substance to prevent the onset of withdrawal symptoms.

A male client has approached the nurse asking for advice on how to deal with his alcohol addiction. Nurse Sally should tell the client that the only effective treatment for alcoholism is:

total abstinence Explanation: Total abstinence is the only effective treatment for alcoholism.

A 16-year-old boy is admitted to the facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include:

violence on television.

A client is admitted to the psychiatric hospital with a diagnosis of catatonic schizophrenia. During the physical examination, the client's arm remains outstretched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm. This client is exhibiting:

waxy flexibility.