Archer Mental Health/ Abuse/Neglect

A client was brought to a local emergency department after police officers located the client walking in a neighborhood at night without shoes in the snow. The client appears confused and disoriented. Which of the following is the priority at this point? A. Assess and stabilize the client medically B. Perform a mental assessment and stabilize the client psychologically C. Locate the nearest family members to obtain the client's history D. Arrange for a transfer to the nearest psychiatric medical facility Submit Answer

Explanation Choice A is correct. Before addressing any existing psychiatric issues which may be present, the client must be fully assessed medically. If one or more medical issues are identified, those issues must be addressed and stabilized. In general, before a client is allowed to be transferred to an inpatient psychiatric treatment facility or floor for treatment, facilities require the client to receive medical clearance (including a urine drug screen, alcohol screen, and a pregnancy test (if applicable)). Various medical conditions may cause a client to present with psychiatric-like symptoms (e.g., substance intoxication/withdrawal, certain electrolyte imbalances, encephalopathy/delirium, infections, traumatic brain injuries, various endocrine disorders, brain malignancy, etc.) and must be ruled out as an underlying cause. Additionally, any client-specific concern must be addressed. Here, since the client was initially located walking barefoot in the snow, one client-specific concern would be the need to evaluate this client for the possibility of frostbite or other related exposure injuries. Choice B is incorrect. Prior to addressing any existing psychiatric issues which may be present, the client must be fully assessed medically. If one or more medical issues are identified, those issues must be addressed and stabilized. Once the client has been evaluated and cleared medically, the priority can shift to addressing the psychiatric assessment and treatment of the client (if indicated). Choice C is incorrect. Before addressing any existing psychiatric issues which may be present, the client must be fully assessed medically. If one or more medical issues are identified, those issues must be addressed and stabilized. Once the client has been evaluated and cleared medically, the priority can shift to addressing the psychiatric assessment and treatment of the client (if indicated). It is important to remember that despite this client being initially located walking barefoot in the snow, the client still has privacy rights under The Health Insurance Portability and Accountability Act of 1996 (HIPAA). Therefore, the nurse should ensure the appropriate methods are used if there is a time in which contact is made with the client's family members. Choice D is incorrect. Prior to addressing any existing psychiatric issues which may be present, the client must be fully assessed medically. If one or more medical issues are identified, those issues must be addressed and stabilized. Once the client has been evaluated and cleared medically, the priority can shift to addressing the psychiatric assessment and treatment of the client (if indicated), including, but not limited to, arranging for a transfer to the nearest psychiatric medical facility. Learning Objective When caring for a confused and disoriented emergency department client brought in by police officers after being found walking in a neighborhood at night without shoes in the snow, identify the current priority as assessing and stabilizing the client medically. Additional Info Before transferring a client to an inpatient psychiatric facility from an emergency department, the accepting inpatient team requires an assessment of medical stability (often referred to as "medical clearance"). Medical clearance is important because up to half of clients with mental health complaints have coexisting non-psychiatric medical conditions that could be causing or exacerbating their psychiatric condition(s). Additionally, a large percentage of psychiatric facilities are often freestanding (i.e., not connected to a general hospital) and consequently have limited ability to care for complex medical problems. The goal of the emergency department-performed medical assessment is two-fold: 1) identify and stabilize any non-psychiatric medical conditions that may be causing or contributing to the client's current symptoms, and 2) identify and stabilize any acute non-psychiatric medical illness (including exacerbations of chronic conditions like chronic obstructive pulmonary disease or diabetes) such that the client may be safely managed at an inpatient psychiatric setting. Last Updated - 16, Jan 2023

The nurse is educating community members on the signs and symptoms of substance abuse intoxication. Which information should the nurse include? Select all that apply. A. Cocaine may cause increased pulse, low blood pressure, and paranoia. B. Inhalants may cause slurred speech, loss of motor coordination, and nausea. C. Heroin may cause increased alertness, paranoia, and increased respirations. D. Alcohol may cause drowsiness, slurred speech, and difficulty with walking. E. Marijuana may cause a slowed reaction time and problems with balance and memory. Submit Answer

Explanation Choices B, D, and E are correct. Depending on the inhalant, an individual may experience a loss of inhibition, headache, nausea, poor muscle coordination, and slurred speech. Alcohol may cause drowsiness, loss of inhibition, and difficulty walking. Marijuana may cause a slowed reaction time, difficulty with learning and memory, and hallucinations. Choices A and C are incorrect. Cocaine is a stimulant and produces significant blood pressure and pulse increases. Psychotic symptoms such as paranoia are also common. Heroin has depressant effects during intoxication and may produce drowsiness, euphoria, sedation, and worse respiratory arrest from decreased respiration. NCLEX Category: Psychosocial integrity Related Content: Chemical and Other Dependencies/Substance Abuse Disorder Question type: Knowledge/comprehension Additional Info See the chart below for the common intoxication symptoms of certain substances. Last Updated - 07, Apr 2022

A 78-year-old woman is brought to the emergency department (ED) for evaluation of an arm injury. During the assessment, the nurse notices contusions in varying stages of healing covering the client's chest and legs. When the nurse asks how the bruises were sustained, the client reluctantly states that her son frequently hits her "if supper is not ready when he gets home from work." Which of the following is the most appropriate nursing response? A. "Oh? Let me talk to your son." B. "I appreciate your honesty, but I need to inform you that I am a mandated reporter, and I am required to report this." C. "Let's talk about how you can manage your time to prevent your son from getting upset." D. "Do you have friends who can help you or keep you safe until you resolve these important issues with your son?" Submit Answer

Explanation Choice B is correct. Under specific state and/or federal laws, nurses are mandated reporters, required to report any suspicion of child or elder abuse. Additionally, depending on the applicable jurisdiction, state law may mandate the nurse to report gunshot injuries, dog bites, specific criminal acts (i.e., rape, etc.), and certain infectious diseases (i.e., HIV, tuberculosis, monkeypox, etc.). The nurse should explain to the client that applicable state and/or federal law(s) require the nurse to report the suspected abuse to a specific entity or authority as outlined in the applicable law. Choice A is incorrect. Confronting the client's son does not rectify the issue, nor does the response address any of the safety concerns of the client moving forward. As a mandated reporter, the nurse must also report the elder abuse suspicions/allegations to the proper authorities. Choice C is incorrect. Teaching the client time management skills would erroneously imply that the client is at fault for this abuse and should therefore be avoided. This statement does not address the fact that the nurse is a mandated reporter of elder abuse. Choice D is incorrect. The client's friends do not have a duty to keep the client safe, nor does the client need to "resolve . . . important issues" with her son. Additionally, this statement does not address the fact that the nurse is a mandated reporter of elder abuse. Learning Objective Identify the correct response when speaking with an elderly client who has just disclosed they are the victim of abuse. Additional Info A mandated reporter, acting in good faith, is typically protected from criminal or civil penalties for reporting suspected abuse if that does not turn out to be the case. When documenting this type of encounter, write what the client has said about the situation in the client's own words. Last Updated - 16, Sep 2022

A 12-year-old client with chronic asthma exacerbations has decided to try guided imagery as a way to manage the anxiety that is contributing to frequent asthma attacks. Which statement by the client indicates an understanding of this stress-reduction technique? A. "I can do this anytime and anywhere when I feel anxious." B. "I must be lying down to practice guided imagery." C. "My mom will have to be with me any time I try this." D. "I will play music every time I do my guided imagery to make sure it works." Submit Answer

Explanation Choice A is correct. Guided imagery is a stress-reduction technique that can be done in any place at any time. In fact, this is one of the biggest advantages of this technique. Anytime the patient begins to feel anxious, they can practice guided imagery. Choice B is incorrect. Guided imagery can be done in any position that the patient is most comfortable in. They do not have to by lying down unless they choose to. Choice C is incorrect. It is not necessary for the client's mom or anyone else to be present for guided imagery unless they choose so. Any person, or no one at all, can be present depending on the client's preferences. Choice D is incorrect. Music can but does not have to be played during guided imagery, again it depends on the client's preferences. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Fundamentals - Alternative Medicine Last Updated - 10, Dec 2021

The home care nurse is assessing a client whose husband passed away nearly half of a year ago. Which of the following is not a robust coping mechanism? A. Looking at photographs of the client's husband B. Getting together with friends more frequently than before C. Having difficulty eating D. Expressing a strong desire to visit their husband's grave every few weeks Submit Answer

Explanation Choice C is correct. Having a difficult time eating nearly half a year after an injury is not a healthy coping mechanism. While typical in the first few weeks following a loved one's death, this length of time indicates a need for intervention. Choice A is incorrect. Looking at old photographs of the patient's husband is a healthy way to deal with grief. Choice B is incorrect. Getting together with friends is an excellent way to cope with grief and loss. Many patients will spend more time with their friends after the passing of a spouse. Choice D is incorrect. Feeling a strong desire to visit a loved one's grave every few weeks is an essential part of the grieving process. NCSBN client need Topic: Psychosocial integrity, Grief and loss Last Updated - 05, Feb 2022

Your adolescent client has been admitted to the adolescent psychiatric mental health unit. What is the first thing that you should do for this client? A. Assess their current psychosocial functioning. B. Generate a nursing diagnosis. C. Establish trust with the client. D. Allow the client to ventilate their feelings. Submit Answer

Explanation Choice C is correct. The first thing that you should do is establish the client's trust. Trust is the early stage of the therapeutic nurse-client relationship. After the trust is established, the nurse should encourage, facilitate, and allow the client to ventilate their feelings. This ventilation of feelings is used for and enfolded into the assessment of the client as well as their current psychosocial functioning; this is often used to generate a nursing diagnosis that is specific to the client's needs. Choice A is incorrect. Although the nurse will assess the client and their current psychosocial functioning, this cannot be done until other phases of the nursing process, and the therapeutic nurse-client relationship is established. Choice B is incorrect. A nursing diagnosis is not established until other phases of the nursing process have been started, including the therapeutic nurse-client relationship. Choice D is incorrect. Although it is necessary to encourage, facilitate, and allow the client to ventilate their feelings, this cannot be done until something else is established. Last Updated - 26, Jan 2022

The nurse is caring for a client demonstrating avolition. The nurse would expect to observe the client have which of the following? A. Loss of balance B. Full range of affect C. Diminished expression D. Lack of motivation Submit Answer

Explanation Choice D is correct. Avolition is a lack of motivation and is a key feature in schizophrenia as well as some depressive disorders. Avolition is categorized as a negative symptom associated with schizophrenia. Choices A, B, and C are incorrect. Loss of balance, full range of affect, and diminished expansion are not findings associated with avolition. Loss of balance would be a problem associated with proprioception. A diminished expression would be consistent with schizophrenia and other psychiatric disorders. This could be termed constricted or flat affect, depending on the significance. Additional Info Avolition is a clinical feature of some psychiatric illnesses, and this includes schizophrenia. This negative symptom may significantly impact a client's socioeconomic status as maintaining employment and social relationships may become difficult. The nurse should maintain the patient's activities of daily living and encourage participation. Last Updated - 16, Feb 2022

Which of the following types of grief are not considered normal and require some interventions from the members of the healthcare team? Select all that apply. A. Complicated grief B. Anticipatory grief C. Unresolved grief D. Grief as the result of a perceived loss Submit Answer

Explanation Choices A and C are correct. Complicated grief and unresolved grief are not considered normal. Both types, therefore, require some interventions from the healthcare team members. Complicated grief is defined as pathological grief; it is characterized by maladaptive coping methods with the loss and the loss of normal functioning six months after the event. Unresolved grief is characterized by an exaggerated and prolonged period of mourning. Choices B and D are incorrect. Anticipatory grief (Choice B) is considered normal; this type of grief occurs when the person reacts to a loss that is anticipated in the future. For example, a woman may have anticipatory grief before the actual loss of the breast with a mastectomy. Grief as the result of a perceived loss (Choice D) is normal. Injuries that occur as the result of both actual and perceived failures must be resolved. Last Updated - 11, Oct 2021

You are performing a thorough assessment of a client to determine all responses to stress. Which of the following are examples of cognitive responses to stress? Select all that apply. A. Difficulty concentrating B. Poor judgment C. Depression D. Forgetfulness E. Lethargy F. Aggressiveness Submit Answer

Explanation Choices A, B, and D are correct. These are examples of cognitive responses to stress. Psychological responses are both emotional and cognitive. They include feelings, thoughts, and behaviors. Emotional responses usually involve anxiety, fear, anger, and depression; whereas, cognitive responses affect thought processes. Choices C and E are incorrect. Depression and lethargy are emotional responses to stress. Choice F is incorrect. Aggression is a behavioral response to stress. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Psychological Responses to Stress Last Updated - 07, Feb 2022

You are admitting a new patient to your acute psychiatric facility and you determine that they have suicidal ideations. Which of the following questions should you ask this patient? Select all that apply. A. Do you have a plan? B. Does anyone else know about your plan? C. What is your plan? D. Do you have the items to carry out your plan? Submit Answer

Explanation Choices A, C, and D are correct. A is correct. "Do you have a plan?" is the first question a nurse should ask any suicidal patient. Patients who have a concrete idea are much more likely to actually attempt suicide than patients who do not have a plan. By discovering your patient's plan, you can take active steps to prevent them from carrying out this plan. C is correct. "What is your plan?" should be the second question a nurse asks a suicidal patient after they have answered yes to having a plan to commit suicide. By discovering exactly what your patient's plan is, you can take active steps to prevent them from carrying out this plan. It is essential to be very, very direct with these questions so that you will get straightforward answers and be able to keep the patient safe. D is correct. This question will depend on what the patient tells you their plan is for committing suicide is. For example, if they say to you that they plan to shoot themselves, the appropriate question would be - "do you have a gun?" This is of the utmost importance for the patient's safety. If they do have a gun, or whatever item is needed to carry out their suicide plan, the nurse needs to have it confiscated immediately to keep them safe. Choice B is incorrect. This is not a question of vital importance. If others do or do not know about your client's suicide plan, it will not change any of your interventions. While admitting a suicidal patient, the nursing priority should be safety. Figuring out what the plan is and if they have the items that they need to carry it out is important so that those items can be confiscated and the safety of the client be maintained. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Psychiatric Nursing Last Updated - 03, Nov 2021

The nurse is assessing a client with schizophrenia. Which of the following would be an expected finding? Select all that apply. A. Apraxia B. Anhedonia C. Avolition D. Delusions E. Bradykinesia Submit Answer

Explanation Choices B, C, and D are correct. Clinical features of schizophrenia include positive and negative symptoms. Anhedonia, avolition, and delusions are all associated with this psychiatric disorder. Choices A and E are incorrect. Apraxia is defined as being unable to complete a purposeful movement. This is a feature associated with several neurological conditions, such as Alzheimer's disease, but is not a feature of schizophrenia. Echopraxia is common with schizophrenia, this is a positive symptom in which the individual mimics the movements of another individual. Bradykinesia is a feature associated with Parkinson's disease, which is slow motor movements. Additional Info Schizophreniaa symptoms are divided into positive or negative symptoms. Positive symptoms include things that add something to the client. They include: Hallucinations: Experiences involving the apparent perception of something not present. They can include any of the five senses: touch, taste, smell, sight, or hearing. Auditory hallucinations, when the client hears something that is not present, are common in schizophrenia. Delusions: Fixed, false beliefs that conflict with reality. Types of delusions include persecution, grandeur, and jealousy Thought and speech disorganization Negative symptoms are things that take something away from the client. They include: Apathy: A lack of interest, enthusiasm, or concern. Alogia: Also known as 'poverty of speech,' alogia is difficulty with speaking or the tendency to speak little due to brain impairment. Anhedonia: The inability to feel pleasure. Avolition: A total lack of motivation that makes it hard to get anything done Flattened affect

You are caring for a client at the end of life with a terminal disease. You overhear this client saying, "Lord, just give me two more months so I can go to my grandson's wedding." What is this client demonstrating with these words? A. Bargaining B. Depression C. Anger D. Denial Submit Answer

Explanation Choice A is correct. Based on Kubler-Ross' stages of death and dying, this statement indicates the client is currently in the bargaining stage. Clients in this stage often attempt to buy time for some future event or occasion. Choice B is incorrect. Depression, according to Kubler-Ross, is characterized by sadness, sorrow, tearfulness, and feelings of helplessness/hopelessness. During this stage, the client would not be asking for more time. Choice C is incorrect. According to Kubler-Ross, the anger stage is characterized by expressions of anger and rage. During this stage, the client would not be asking for more time. Choice D is incorrect. Denial, according to Kubler-Ross, is characterized by the subconscious thought that death is not imminent. Learning Objective Correlate the client's statement with the bargaining stage of Kubler-Ross' stages of death and dying. Additional Info The stages of death and dying, according to Kubler-Ross, in the correct sequential order are: Denial Anger Bargaining Depression Acceptance Last Updated - 25, Nov 2022

Which of the following nursing interventions are appropriate for a manic patient experiencing delusions of grandeur? Select all that apply. A. Refrain from talking excessively about their delusion B. Set boundaries C. Enforce three meals a day D. Argue that their delusions are not your reality Submit Answer

Explanation Choices A and B are correct. It is essential to refrain from talking much about the delusions that your manic patient is having. Delusions of grandeur, such as the patient thinking they are god, come from a need for them to feel necessary and proper about themself. You need to support the patient's confidence in a realistic way. By refraining from talking excessively about the delusion, you are not supporting its reality, which is therapeutic for the patient (Choice A). Setting boundaries and limits are incredibly crucial for the manic patient. These patients can be incredibly manipulative and by setting limits, you will be helping them come back down to reality. Consistency is also key to these boundaries. For example, if you make a rule that lights must be off at 10:00 pm each night, this rule should be followed every single night without exception (Choice B). Choice C is incorrect. Enforcing three meals a day will not work for the manic patient. They are too busy to sit down for a large meal and will end up just forgetting to eat. This can lead to severe malnutrition and dehydration. It is essential to provide the patient with finger foods and stay with them while they walk and eat. Keep them calm and try to maximize the calories that they are getting instead of trying to enforce sitting through three meals a day. Choice D is incorrect. It is not therapeutic to argue with a manic patient. These patients are very manipulative and argumentative. They will fight back and their behavior will escalate. It is essential to help guide them towards reality by setting boundaries and letting them know their delusion is not your reality, but you should never argue. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Psychiatric Nursing Last Updated - 22, Dec 2021

The nurse assists the client in developing goals while hospitalized. This phase of the nurse-client relationship is best described as which of the following? A. Orientation phase B. Working phase C. Termination phase D. Pre-interaction phase Submit Answer

Explanation Choice A is correct. The orientation phase is characterized by the nurse and the client becoming familiar with each other. Establishing goals that are reasonable and important to the client is a classic component of the orientation phase. Choices B, C, and D are incorrect. The working phase is characterized by problem-solving and maintaining the therapeutic rapport with the client. Goals should have been established during the orientation phase. The termination phase hallmarks the end of the nurse-client relationship that reflects the progress made on the goals. The pre-interaction phase is when the nurse examines their thoughts and feelings to avoid countertransference. Additional Info A therapeutic rapport with a client is essential regardless of the clinical setting. The nurse-client relationship is different from a social relationship in that it focuses on the client and their needs. It is essential that the nurse protects the therapeutic alliance with the client throughout all phases and promotes measures to keep it strong. A strong therapeutic rapport enables the client to be honest with the nurse and portrays respect. Last Updated - 06, Dec 2022

Fear and anxiety are quite similar. However, there are differences. Select the statements below that are accurate in terms of differentiating fear from anxiety. Select all that apply. A. Fear is related to the present danger, whereas anxiety is related to future danger. B. Anxiety is secondary to a psychological stressor, whereas fear is secondary to a physical or psychological stressor. C. Fear is secondary to an identifiable source, whereas anxiety is secondary to an unidentifiable source. D. Anxiety is diffuse and vague, whereas fear is more specific and definable. Submit Answer

Explanation Choices B, C, and D are correct. Anxiety is secondary to a psychological stressor, whereas fear is secondary to either a physical or psychological stressor (Choice B). Anxiety is secondary to an unidentifiable source, whereas fear is secondary to an identifiable source (Choice C). Anxiety is diffuse and vague, whereas fear is more specific and definable (Choice D). Choice A is incorrect. Fear can be related to past, present, or future threats or stressors. Last Updated - 17, Oct 2021

An altered physical condition caused by the nervous system adapting to repeated drug use is: A. Addiction B. Physical dependence C. Psychological dependence D. Withdrawal Submit Answer

Explanation Choice B is correct. Some drugs are frequently abused or have a high potential for addiction. Drugs that cause dependency are restricted to use in situations of medical necessity if they are allowed at all. According to law, drugs that have a significant potential for abuse are placed into categories called schedules. Choices A, C, and D are incorrect. Addiction refers to the overwhelming feeling that drives someone to use a drug repeatedly, although it is not medically necessary. Psychological dependence occurs when an individual has few signs of physical discomfort when a drug is withheld. However, the individual feels an intense, compelling desire to continue the use of the drug. Withdrawal is a term used to describe physical signs of discomfort that an individual experiences when a drug is no longer available. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies Last Updated - 13, Feb 2022

The nurse is caring for a client who is of the Islamic faith. The client has died. The nurse should take which appropriate action? A. Prepare the client for cremation B. Position the client facing Mecca C. Keep the client's eyelids open D. Keep the client uncovered Submit Answer

Explanation Choice B is correct. For a client of the Islamic faith, death practices include keeping the client covered, closing their eyelids, and placing the client-facing Mecca (the East). Choices A, C, and D are incorrect. The client's eyes should be closed, and the client should be appropriately covered, as modesty is essential in this religion. The Islamic religion prohibits cremation. Additional Info For the client who is a follower of Islam, general tenets of this religion include: The eyelids should be closed at death, and the body should be covered. Before moving and handling the body, contact someone from the person's mosque to perform rituals of bathing and wrapping the body in cloth. Death may be viewed as the beginning of a new life. Dietary practices include the avoidance of pork. Ramadan is a period of fasting during the ninth lunar month. During Ramadan, fasting is done from dawn to sunset. Women prefer healthcare workers that are female and value modesty. Last Updated - 10, May 2022

When providing care for a patient with known IV drug use, which statement would be appropriate for the nurse to discuss to highlight the risk factors of this behavior? A. The use of these drugs can increase the risk of contracting diseases due to immunosuppression. B. IV drug use can lead to skin infections at the injection sites and poor health. C. The risk of contracting and spreading bloodborne pathogens such as HIV, which can progress to AIDS, is a considerable risk factor for this activity. D. Drug use can lead to unsafe sex practices, increasing the risk of transmission of sexually transmitted diseases/infections. Submit Answer

Explanation Choice C is correct. HIV is a blood-borne pathogen, therefore sharing needles with IV drug abusers exponentially increases the risk of contracting the disease. Choices A, B, and D are incorrect. Although all of these answer choices are true, the most appropriate statement for the nurse to discuss is reflected in choice C. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control; The Use of Alcohol and Illicit Drugs Last Updated - 06, Feb 2022

As part of your psychosocial assessment of a 46-year-old female client, you would most likely assess which of the following in the client? A. Level of development [21%] B. Electrolyte levels [9%] C. Affect [62%] D. Effect [8%]

Explanation Choice C is correct. You would most likely assess the client's affect and mood as part of your psychosocial assessment of a 46-year-old female client. The effect is an indicator of the client's psychological disposition. For example, a flat affect indicates the abnormal absence of emotion. Choice A is incorrect. The level of development may come into consideration for this client; however, this assessment is most often and likely done with pediatric clients rather than adult clients. Choice B is incorrect. Electrolyte levels are part of a client's physical assessment and not a part of a psychosocial evaluation. Choice D is incorrect. The effect is the result of a cause and it is not related to the psychosocial assessment of clients. Last Updated - 09, Feb 2022

A client is admitted to the psychiatry ward because of anorexia nervosa. Which assessment parameter should the nurse prioritize? A. The client's weight and height. B. The client's electrolyte levels. C. The concerns of the client's family. D. The client's medical history. Submit Answer

Explanation Choice B is correct. Clients with anorexia nervosa have altered serum electrolyte levels. The nurse should initially assess the client for hypokalemia, which can pose difficult, life-threatening situations to the client. Choice A is incorrect. Taking the client's weight and height is a necessary parameter to be assessed; however, it should not take priority over the client's electrolyte levels. Choice C is incorrect. The nurse should address concerns of the client's family; however, this should not take priority over the client's physiological needs. Choice D is incorrect. The client's medication history is a critical assessment, but physiological needs should be met first. Last Updated - 09, Feb 2022

A patient admits that he thinks he has a problem with drinking too much alcohol. The nurse talks with the patient about substance abuse and the adverse effects of alcoholism. Which best describes how personal engagement with a patient is an active method of change? A. The patient will understand the information more than if it were presented electronically. B. The patient will be less likely to be litigious toward the healthcare facility. C. The patient will more likely desire change after connecting with another person. D. The patient will feel as if he has made a new friend. Submit Answer

Explanation Choice C is correct. Feeling connected to another person gives a sense of belonging and acceptance. The patient will be more likely to change after joining with another person. Change is necessary when a patient is exhibiting behaviors that are harmful to himself or others. Change can be implemented in many ways, but personal engagement, or talking, working with, and spending time with another person, can be useful in getting the message across about the high-risk behavior. With personal engagement, the patient is more likely to desire change because he feels a connection with another person. Choices A and B are incorrect. While these options may be right, they do not reflect the importance of personal engagement and how it affects change. Choice D is incorrect. When nurses facilitate personal engagement with a client, this is not a friendship, but rather a provider-client relationship. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Therapeutic Communication Last Updated - 10, Nov 2021

The nurse is planning care for a client with a borderline personality disorder. The nurse recognizes that the client will likely demonstrate which defense mechanism? Select all that apply. A. Splitting B. Sublimination C. Altruism D. Projection E. Conversion Submit Answer

Explanation Choices A and D are correct. Severe impairments in functioning characterize borderline personality disorder. Its major features are patterns of marked instability, impulsivity, identity or self-image distortions, unstable mood, and unstable interpersonal relationships. Splitting is a hallmark manifestation of this disorder in which an inability to view both positive and negative aspects of others as part of a whole, results in viewing someone as either a wonderful person or a horrible person. Projection is also a cardinal defense mechanism for this disorder in which an individual unconsciously rejects emotionally unacceptable features and attributes them to others. Choices B, C, and E are incorrect. Sublimination and altruism are generally constructive defense mechanisms and not employed by a client with BPD. Conversion is characterized by the unconscious transformation of anxiety into a physical symptom with no organic cause. Additional Info A borderline personality disorder is about five times more common in first-degree biological relatives with the same disorder compared with the general population. This disorder is highly associated with genetic factors such as hypersensitivity, impulsivity, and emotional dysregulation. A key intervention for a client with BPD is to assess for suicidality. Parasuicide is common with this personality disorder; however, it is essential to keep this client safe. Defense mechanisms commonly seen in this personality disorder include splitting, projective identification, and denial. Last Updated - 21, Jun 2022

The nurse is assessing a client with delirium. Which of the following would be an expected finding? Select all that apply. A. Impaired insight into illness B. Difficulty with executive functioning C. Altered level of consciousness D. Emotional lability E. Insidious onset of symptoms Submit Answer

Explanation Choices A, B, C, and D are correct. Delirium has an abrupt onset of symptoms that include - Impairments with attention that fluctuate in intensity Difficulty with insight, judgment and executive functioning Memory impairments Altered level of consciousness Emotional lability Causes of delirium include fluid and electrolyte imbalances, infection, medications, sensory alterations, or substance use (intoxication/withdrawal). Choice E is incorrect. A key difference between delirium and dementia is that delirium has an abrupt onset. Dementia has an insidious onset that is progressive. Symptoms associated with delirium may fluctuate in intensity. Additional Info Last Updated - 23, Jun 2022

Which of the following are a type of social support? Select all that apply. A. An emotional social support B. An informational social support C. A physical help social support D. A sensory social support E. An instrumental social support F. An appraisal social support Submit Answer

Explanation Choices A, B, E, and F are correct: Choice A is correct. An emotional, social support is one type of social support. Passionate social support people and networks provide clients with the emotional and psychological support that is often needed to decrease client stress and enhance client coping. Choice B is correct. An informational social support is one type of social support. Informational social support people and networks provide clients with the knowledge and skills needed to adapt to and cope with a stressor. Choice E is correct. An instrumental social support is one type of social support. Helpful social support people and networks provide clients with tangible help, for example: transportation and household help. Choice F is correct. An appraisal of social support is one type of social support. Appraisal social support people and networks provide clients with the opportunity to gain insight and to self evaluate their strengths and limitations. Choices C and D are incorrect: Choice C is incorrect. Physical help social support is non-existent. The four types of social support are informational, emotional, instrumental, and appraisal support systems. Choice D is incorrect. Sensory social support is non-existent. The four types of social support are informational, emotional, instrumental, and appraisal support systems. Last Updated - 27, Apr 2021

Which of the following findings may indicate a change in mental status? Select all that apply. A. Asymmetrical movements B. Lethargy C. Disheveled appearance D. Rapid speech Submit Answer

Explanation Choices B, C, and D are correct. Changes in appearance, speech, and alertness may indicate a change in mental status and require further evaluation. An alteration in mental status refers to general changes in brain function, such as confusion, amnesia (memory loss), loss of alertness, disorientation (not conscious of self, time, or place), defects in judgment or thought, unusual or strange behavior, poor regulation of emotions, and disruptions in perception, psychomotor skills, and practice. While an altered mental status is characteristic of several psychiatric and emotional conditions, medical conditions and injuries that cause damage to the brain, including alcohol or drug overdose and withdrawal syndromes, can also cause mental status changes. Confusion, lethargy, delirium, dementia, encephalopathy, and organic brain syndrome are all terms that have been used to refer to conditions hallmarked by mental status changes. Choice A is incorrect. Asymmetrical movements may indicate a stroke and a specific change in neurological status. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Mental Status Last Updated - 16, Dec 2020

The nurse is caring for a client who is receiving prescribed varenicline. Which of the following statements would indicate a therapeutic response if made by the client? A. "I am not smoking cigarettes anymore." B. "My depression has gotten better." C. "I am sleeping eight hours a night." D. "I can focus on one task at a time." Submit Answer

Additional Info A combination of medications and behavioral therapy works best for smoking cessation rather than either treatment alone. Most smoking cessation medications work by reducing nicotine withdrawal and craving. Medicines for smoking cessation include nicotine replacement therapy (NRT), varenicline, and bupropion. Varenicline is a preferred option for most patients. Varenicline is administered as an oral pill. It works by relieving nicotine withdrawal symptoms and blocking the smoking-related reward feeling. For a patient taking varenicline, starting the medication one week before quitting cigarettes is recommended. The patient may continue the treatment for up to twelve weeks. The most common side effect of varenicline is nausea. Adversely, neuropsychiatric effects such as vivid dreams, depression, and suicidal ideation have been reported. Varenicline should not be used in patients with a history of suicidal ideation or unstable psychiatric illness. Nicotine replacement therapy (NRT) is available in various forms ( patch, lozenge, gum, inhaler, and nasal spray). NRT may be prescribed as a first-line choice based on the client's preference. Adverse effects include insomnia and vivid dreams. Bupropion is less effective compared to NRT or varenicline. However, it's a preferred choice for patients with depression because bupropion can work as an anti-depressant. Additionally, bupropion promotes weight loss and may be preferred for clients wishing to avoid weight gain following smoking cessation. Bupropion reduces the seizure threshold, and consequently, it is contraindicated in patients with a seizure disorder. Ongoing counseling should be pursued to enhance a patient's success at smoking cessation.

Which of the following is an appropriate crisis intervention technique to assist a client who has severe depression and thoughts of suicide? A. Privacy and a client room without stimulation or the presence of others. B. An empathetic and non-judgmental exploration of the client's feelings. C. Probing the client for details of their suicide plan. D. The use of restraints and seclusion. Submit Answer

Explanation Choice B is correct. An empathetic and non-judgmental exploration of the client's feelings and facilitating the client's open verbalization of their beliefs is the only appropriate crisis intervention technique to assist a client who has severe depression and thoughts of suicide, as based on the client's information provided in this question. Choice A is incorrect. Privacy and a client room without stimulation or the presence of others are contraindicated with severe depression and thoughts of suicide because one-to-one monitoring is necessary. Choice C is incorrect. Probing the client for details of their suicide plan is not an appropriate crisis intervention technique to assist a client who has severe depression and thoughts of suicide because probing is not therapeutic. It is also invasive. Choice D is incorrect. The use of restraints and seclusion is not an appropriate crisis intervention technique to assist a client who has severe depression and thoughts of suicide because control and privacy are not indicated until all other preventive alternative interventions have failed. The client is in immediate danger, which is not found in this question. Last Updated - 14, Feb 2022

While working in the emergency department, the nurse sees each of the following clients. As a mandated reporter, the nurse knows which client is at highest risk for elder abuse? A. A 70-year old female with orthostatic hypotension. B. An 86-year old female with glaucoma. C. A 92-year old male with late-stage Alzheimer's disease. D. A 75-year old male with leukemia. Submit Answer

Explanation Choice C is correct. A 92-year old male with late-stage Alzheimer's disease is at very high risk for elder abuse. This can include both physical and psychological abuse. Elders with late-stage Alzheimer's disease are at very high risk because of the memory loss and confusion that occurs with this disease. Choice A is incorrect. A 70-year old female with orthostatic hypotension may be at risk for elder abuse, but there is another answer choice with a higher risk individual. Choice B is incorrect. An 86-year old female with glaucoma may be at risk for elder abuse, but there is another answer choice with a higher risk individual. Choice D is incorrect. A 75-year old male with leukemia may be at risk for elder abuse, but there is another answer choice with a higher risk individual. NCSBN Client Need Topic: Psychosocial Integrity; Subtopic: Geriatrics - Mental Health Last Updated - 01, Feb 2022

The nurse is caring for a client newly admitted to the mental health unit with bulimia nervosa. Which client statement requires immediate follow-up? A. "These sores in my mouth hurt." B. "When can I weigh myself?" C. "I hate my life and wish it was over." D. "I feel really dizzy right now." Submit Answer

Explanation Choice D is correct. The physical needs of the client with a mental health disorder prioritize over psychosocial needs. The client experiencing dizziness is highly concerning because this could be suggestive of severe dehydration or other electrolyte imbalances. Choices A, B, and C are incorrect. Dental caries, sores in the oral mucosa, electrolyte disturbances, dehydration, irregular menses, and calluses on the fingers are all manifestations associated with bulimia nervosa. A client expressing self-negating statements requires follow-up but does not prioritize over the client endorsing dizziness. Additional Info Maslow's Hierarchy of Needs signifies that physical needs must be assessed and cared for first before psychological needs can be satisfied. Thus, the priority is to take care of the client's physical need of dizziness as this is a manifestation associated with significant dehydration. Last Updated - 15, Feb 2022

A woman comes into the emergency department with multiple bruises on the face and head. The nurse suspects that intimate partner violence (IPV) may be the cause of her injuries. What is the most appropriate action for the nurse to take at this time? A. Ask the person if she is afraid of someone at home who is hurting her. B. Refer the person to a shelter for battered women. C. Call a social worker to assess the person for IPV. D. Document the concern in the chart, but do nothing else. Submit Answer

Explanation Choice A is correct. Asking the patient if he or she is afraid of someone at home or if they are being hurt at home is the first critical step in a comprehensive assessment. Intimate partner violence (IPV) is a serious problem for men and women of all socioeconomic and cultural backgrounds. Age is also not a defining factor for potential victims, either. Nurses should suspect IPV when injuries are not consistent with the history given by the client. Choice B is incorrect. Referring the patient to a shelter before a complete assessment is done may lead to inappropriate care. Choice C is incorrect. While collaboration with other health professionals may be necessary, the first step is a comprehensive assessment by the nurse. Choice D is incorrect. Documentation alone does not address, reduce, or solve the concern. NCSBN Client Need Topic: Safe & Effective Care Management, Subtopic: Safety & Infection Control Last Updated - 11, Feb 2022

Select the ego defense mechanism that is accurately paired with an example of how an individual can use it to cope psychologically with a stressor. A. Repression: A young child forgets that he saw his parents brutally murdered B. Regression: A young child forgets that he saw his parents brutally murdered C. Displacement: A person becomes a religious fanatic to overcome their hatred of religions D. Displacement: A criminal mimics the behaviors of law abiding citizens Submit Answer

Explanation Choice A is correct. Repression is the ego defense mechanism that is accurately paired with the example of a young child who has no memory of seeing his parents being brutally murdered. This is how an individual can use defense mechanisms to cope psychologically with a stressor. Repression protects the person from undue and immense stress until they are better able to cope with it. Choice B is incorrect. The child is not using regression when forgetting that he saw his parents being brutally murdered. Regression is reverting to an earlier developmental or maturation stage to cope with stress, not amnesia. Choice C is incorrect. A person who becomes a religious fanatic to overcome their hatred of religions is doing the opposite of what they genuinely believe by using reaction formation, not displacement. Choice D is incorrect. A criminal who mimics the behaviors of law-abiding citizens is using identification, not displacement. Additional Info Last Updated - 12, Feb 2022

Which of the following patients is at greatest risk for sensory deprivation? A. An older man who is confined to bed at home following a stroke. B. An adolescent in an oncology unit who is working on homework supplied by her friends. C. A woman in active labor. D. A toddler in a playroom awaiting same-day surgery. Submit Answer

Explanation Choice A is correct. The patient in this option is confined to bed and has visits/interactions with others that may be limited leading to sensory deprivation. The reticular activating system (RAS) is a network of neurons located in the brain stem that projects anteriorly to the hypothalamus to mediate behavior. Sensory deprivation results when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. With decreased sensory input, the RAS is no longer able to project a normal level of activation to the brain. As a result, the person may hallucinate simply to maintain an optimal level of arousal. Factors that place patients at a higher risk for sensory deprivation may include: An environment that has decreased stimuli Impaired ability to receive environmental stimuli (impaired vision or hearing) Inability to process environmental stimuli (patients with spinal cord injuries, brain damage, or confused/disoriented patients) Choices B, C, and D are incorrect. All of these answer choices reflect patients who are in environments in which environmental stimuli are adequate to prevent sensory deprivation. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Sensory Deprivation Last Updated - 08, Nov 2021

The nurse supervises a novice nurse interviewing a client with a borderline personality disorder. Which client statement would demonstrate the client using transference? A. "You are just like my mother bothering me with these questions." B. "Instead of breaking objects, I have joined a kickboxing class." C. "I cannot be an alcoholic because I still go to work every day." D. "I told my boyfriend if he leaves me, I will kill myself." Submit Answer

Explanation Choice A is correct. This is an example of transference. In transference, the client's unconscious feelings toward a healthcare worker come to the surface that originally stems from someone else. For instance, if a client starts to have hostility towards the healthcare worker because they remind them of a family member with whom they had (or have) a negative relationship. The client bringing up their mother and pinning it on the healthcare worker exemplifies transference. Choices B, C, and D are incorrect. Instead of breaking objects, the client joining a kickboxing class demonstrates sublimination, a positive defense mechanism. The client denying their alcoholism is an example of denial, which is a common defense mechanism used in borderline personality disorder. The client stating she will kill herself if her boyfriend leaves her is an example of manipulation. This is commonly used in borderline personality disorder. Additional Info Transference refers to the client's unconscious feelings toward a healthcare worker originally felt in childhood for a significant other. The client may say something like, "You remind me exactly of my brother." Countertransference refers to unconscious feelings that the healthcare worker has toward the client. For instance, if the client reminds you of someone you do not like, you may unconsciously react as if the client were that individual. Halter, M. (082021). Varcarolis' Foundations of Psychiatric-Mental Health Nursing, 9th Edition. Last Updated - 18, Nov 2022

While working in the emergency department, you triage a 29-year-old female who states, "I am going to kill myself. They're coming for me!" Which of the following responses utilizes a therapeutic form of communication? A. "You are safe here. Can you tell me what is happening?" B. "Please don't try to kill yourself. We will sedate you if we have to." C. "Why would you kill yourself?" D. "Who is coming for you?" Submit Answer

Explanation Choice A is correct. This statement uses therapeutic communication by helping the client feel safe and asking open-ended questions to gather more information. Choice B is incorrect. Telling the client not to kill themselves will not work for this patient. Instead, it will increase the likelihood of them trying to do so. Furthermore, it is never therapeutic to threaten to sedate a patient. Choice C is incorrect. Asking 'why' questions are never therapeutic communication. This can seem judgemental and make the client defensive rather than open up to you. Choice D is incorrect. This question endorses the client's thought that someone is coming for them by asking them 'who'. This is also a closed-ended question that will not promote further conversation. In therapeutic communication, you should use open-ended questions. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Adult Health, Mental Health Nursing Last Updated - 14, Feb 2022

Select the therapeutic communication technique that is accurately paired with an example of it. A. Reflecting: "I really believe that you should not be thinking in this self-destructive and self-deprecating manner." B. Seeking clarification: "I am sorry. Could you restate that thought so I can be clear about what you are saying?" C. Offering of self: "I am here to talk with you about your fears because you have refused to talk about these before." D. Probing: "It is now time for you to start telling me about your substance abuse problem without further delay." Submit Answer

Explanation Choice B is correct. "I am sorry. Could you restate that thought so I can be clear about what you are saying?" is an example of seeking clarification, which is a therapeutic communication technique. Seeking clarification aims to ensure that the receiver of the message is precise and clear about the meaning of the sender's word. Choice A is incorrect. "I believe that you should not be thinking in this self-destructive and self-deprecating manner" is not at all a therapeutic communication technique. It is highly judgmental and not conducive to a therapeutic nurse-client relationship. Instead, the nurse should allow the client to ventilate these feelings and then attempt to work with the client to resolve these feelings. Choice C is incorrect. "I am here to talk with you about your fears because you have refused to talk about these before" is not at all a therapeutic communication technique. It is highly judgmental and not conducive to a therapeutic nurse-client relationship. Instead, the nurse should offer help and allow the client to vent their fears and concerns in an environment of openness, trust, caring, and compassion. Choice D is incorrect. "It is now time for you to start telling me about your substance abuse problem without further delay" is not at all a therapeutic communication technique. It is highly authoritative, judgmental, and not conducive to a therapeutic nurse-client relationship. Instead, the nurse should not probe the client but, instead, allow the client to ventilate about their substance abuse problem in an environment of openness, trust, caring, and compassion. Last Updated - 18, Jan 2022

A nursing student in a pediatric unit at a hospital asks the clinical nurse educator about a nurse's legal responsibilities in cases of suspected child abuse. Which of the following would be the most appropriate response by the nurse educator? A. A nurse is required to collect additional data to support their suspicion before taking further action. B. A nurse is required to directly report their suspicions to the local child protection agency and/or law enforcement agency. C. A nurse is required to talk to a child's parents regarding any suspected abuse. D. A nurse is required to talk to the health care provider (HCP) regarding their suspicions of child abuse. Submit Answer

Explanation Choice B is correct. A nurse's legal responsibility is to immediately report any suspected child abuse to the relevant authorities according to state and local law(s). Once any suspicion forms, the nurse is required to report the suspicion to the appropriate investigative agency or agencies per applicable law, which then assumes the investigation. Choice A is incorrect. The data which has led the nurse to suspect child abuse should be sufficient to prompt the nurse to report the suspicions to the authorities. The nurse should not waste additional time or resources accumulating additional information, as the additional time used to collect those resources will lead to delayed intervention. Choice C is incorrect. This step should be avoided. Speaking to the suspected victim's/pediatric client's patients will likely aggravate the parents, resulting in additional negative repercussions against the child. Furthermore, the situation may worsen (i.e., increased abuse, the family may suddenly relocate, etc.). Choice D is incorrect. Discussion with the HCP does not guarantee notification of the authorities of this case. Child abuse reporting is not something you "pass up the chain of command." While the nurse may discuss the issue with the HCP, this discussion does not negate the nurse of their duty to report their suspicions under the law. Learning Objective Recognize a nurse's legal responsibilities regarding the reporting of suspected child abuse. Additional Info State laws, local laws, and hospital policies should always be consulted in these situations. It is essential to note that a variety of individuals (including, but not limited to, various types of healthcare providers, such as nurses) have a legal duty to report under the law. All states and provinces in North America have laws regarding the mandatory reporting of child abuse. Last Updated - 03, Sep 2022

The clinic nurse notices bruises at multiple stages of healing on a 2-year-old. The nurse also sees a couple of burns on the toddler's trunk. What would be the nurse's most appropriate action? A. Confront the child's parents B. Call Child Protective services C. Check the child again after two weeks D. Call the physician Submit Answer

Explanation Choice B is correct. Bruises and burns in a child indicate abuse. Once the nurse suspects child abuse, he/she is responsible for notifying Child Protective Services. Choice A is incorrect. The nurse is not in a position to confront the parents regarding the bruises and burns of the child, especially if the nurse is in a home visit. This would compromise the nurse's safety. Choice C is incorrect. The nurse should not wait for another moment to report the child as additional harm might come to the child. Choice D is incorrect. Calling the physician does not remove the child from danger. The nurse may need to call the physician, but the nurse should call child protective services first. Last Updated - 29, Jan 2022

Which form of therapy would most likely be used to treat a group of clients affected by phobias? A. Behavioral psychotherapy B. Cognitive behavioral psychotherapy C. Psychoanalysis D. Cognitive psychotherapy Submit Answer

Explanation Choice B is correct. Cognitive-behavioral therapy (CBT) is a treatment that combines cognitive psychotherapy and behavioral psychotherapy. CBT is recommended as a first-line treatment approach for specific phobias. The behavioral component of CBT involves repeated exposure to the feared situations and thereby promotes fear reduction. For example, a virtual reality exposure strategy using computer technology can be used to simulate real-life situations (e.g. treating fear of flying with repeated exposure in a flight simulator). The cognitive component of CBT facilitates the client to identify the maladaptive thoughts relating to stressors and replace them with realistic thoughts. For example, a client with a specific phobia of elevators may incorrectly believe there is an extremely high chance of getting stuck while in an elevator. This distorted belief can be addressed with cognitive therapy and thereby reduce fear. CBT is also used for generalized anxiety disorder, panic disorder, eating disorders (anorexia nervosa, bulimia), and obsessive-compulsive disorder (OCD). Choice A is incorrect. Behavioral psychotherapy is useful for patients adversely affected by substance-related disorders and other addictive disorders. Some of the techniques used with behavioral therapy include operant conditioning as put forth by Skinner, aversion therapy, desensitization therapy, modeling, and complementary and alternative stress management techniques. Choice C is incorrect. Psychoanalysis deals with the client's subconscious and focuses on the past and current issues. Psychoanalysis and psychodynamic psychotherapy have been used in treating anti-social personality disorders. Choice D is incorrect. Cognitive psychotherapy is primarily used to treat patients with depression, anxiety disorders, or eating disorders. Cognitive therapy is aimed at altering the client's perspective and attitudes relating to stressors. Learning objective: Cognitive-behavioral therapy combines cognitive and behavioral psychotherapy strategies and is the standard first-line treatment for phobias. NCSBN Client Need: Topic: Psychosocial integrity; Sub-Topic: Behavioral interventions Last Updated - 06, Feb 2022

The nurse is performing an admission assessment on a client admitted to the behavioral health unit. The client is reporting new-onset blindness after witnessing a traumatic motor vehicle accident. The nurse suspects that this client is using which defense mechanism? A. Suppression B. Conversion C. Displacement D. Dissociation Submit Answer

Explanation Choice B is correct. Converting anxiety into physical symptoms with no organic cause best explains this defense mechanism this client is experiencing. Conversion is a pathological defense that may manifest as a disorder if it continues to recur. This client was traumatized by the accident and converted his anxiety into a physical symptom (blindness). His new-onset blindness has no organic origin; thus, this exemplifies conversion. Choices A, C, and D are incorrect. Suppression is defined as the conscious decision to delay addressing a disturbing situation. The client does not exhibit this avoidance because they have taken their anxiety and manifested it as a physical ailment that cannot be explained. Displacement is the transference of emotions associated with a particular person, object, or situation to another non-threatening person, object, or situation. This client has not transferred their anxiety to someone (or something). Finally, dissociation is a disruption in consciousness, memory, identity, or perception of the environment that results in compartmentalizing uncomfortable or unpleasant aspects of oneself. This client has no evidence of a disruption in their consciousness, memory, or identity. Additional Info Adaptive use of defense mechanisms helps people to lower their levels of anxiety and to achieve their goals in acceptable ways. Maladaptive use of defense mechanisms occurs when one or several are used to excess, particularly immature defenses. Most defense mechanisms can be used in both healthy and unhealthy ways. People generally use a variety of defense mechanisms but not always to the same degree. Last Updated - 05, Sep 2022

The nurse is caring for a client in the emergency department (ED) experiencing delirium tremens. The nurse should take which initial action? A. Assess the client's pain level. B. Implement seizure precautions. C. Obtain a prescription for chlordiazepoxide. D. Administer the Glasgow Coma Scale (GCS). Submit Answer

Explanation Choice B is correct. Delirium Tremens (DTs) is a medical emergency that may result in seizure activity. The nurse should always put the client's safety at the forefront and provide seizure precautions. This includes padding the side rails, ensuring that intravenous access has been established, oxygen is at the bedside, and suction is available. Choices A, C, and D are incorrect. While assessing a client's pain is an essential task, this is not a pertinent assessment for DTs. The nurse should assure client safety by implementing seizure precautions. Obtaining a prescription for chlordiazepoxide (benzodiazepine) is a reasonable task but does not prioritize over assuring client safety. Benzodiazepines are the hallmark in preventing seizure activity in DTs and increasing the client's comfort during DTs (they experience tachycardia, hypertension, flushing, and diaphoresis). A GCS is not a relevant assessment for DTs, as The Clinical Institute, Withdrawal Assessment Alcohol Scale-Revised (CIWA-Ar) is utilized to determine the severity of the withdrawal. Additional Info Delirium Tremens (DTs) is a medical emergency and may cause autonomic hyperactivity, resulting in tachycardia, diaphoresis, fever, anxiety, insomnia, and hypertension. Delusions and visual and tactile hallucinations are common in alcohol withdrawal delirium. This may occur during 72 hours following the last alcoholic beverage consumed. Withdrawal seizures may occur within 12 to 24 hours after alcohol cessation. These seizures are generalized and tonic-clonic. Additional seizures may occur within hours of the first seizure. Diazepam is given intravenously as a common treatment for withdrawal seizures. Nursing care for DTs include - Rapid assessment of the client's vital signs Initiate seizure precautions and establish patent intravenous access Obtain a prescription for benzodiazepines, such as lorazepam or diazepam Administer intravenous fluids and electrolytes to replete the lost fluids Assess the client using the CiWa-Ar scale to trend the severity of the symptoms Last Updated - 01, May 2022

A client in the primary healthcare provider (PHCP) office is observed getting yelled at by their spouse. When the nurse interviews the client, the client is hostile and shouts at the nurse. This client is exhibiting which defense mechanism? A. Identification B. Displacement C. Undoing D. Compensation Submit Answer

Explanation Choice B is correct. Displacement is the ego defense mechanism that a client will most likely employ to cope with the stressors associated with lashing out at a target with socially unacceptable hostility. For example, a client under attack by another individual does not react and displaces their reaction (which is often intensified) on someone else. In this case, the spouse shouted at the client, which led to the client unloading their reaction to that conflict by being hostile to the nurse. Choices A, C, and D are incorrect. Identification is copying and mimicking the behaviors of others to overcome their feelings of inadequacy and lack of value. Undoing is the ego defense mechanism used when someone undoes something that has made them feel guilty, such as buying the wife a bouquet after being unfaithful. Compensation occurs when a person maximizes some strength to overcome feelings of weakness and inadequacy.

The nurse is caring for a client admitted involuntarily and prescribed electroconvulsive therapy (ECT). Prior to transferring the client to the procedure room, the nurse observes that the consent form has not been signed. The nurse should understands that A. informed consent should be obtained from the client's wife. B. informed consent should be obtained from the client. C. informed consent is not necessary. D. informed consent needs to be obtained from the court. Submit Answer

Explanation Choice B is correct. Even though the client is involuntarily admitted, the client does not lose the right to informed consent. Informed consent must be obtained from the client. Choices A, C, and D are incorrect. Unless declared legally incompetent, the client's wife does not have the authority to consent on the client's behalf. Electroconvulsive therapy needs informed consent from the client to proceed. Unless deemed legally incompetent, informed consent must be obtained from the client. Additional Info When a client is admitted involuntarily, the only client right that is waived is the right to leave. The client still has the right to consent and refuse treatments, procedures, and medications. Last Updated - 28, Dec 2022

The nurse is assessing a client with a binge eating disorder. The nurse understands which other comorbidity is commonly found with this disorder? A. Disorganized behavior B. Depression C. Fear of abandonment D. Perfectionism Submit Answer

Explanation Choice B is correct. Individuals who binge eat are more likely to have depression (and/or anxiety) than those who do not. Therefore, following this client admitting to binge eating, the nurse should screen this client for depression and suicidal ideation. Depression associated with the binge-eating disorder could be linked to their body image; however, other causes may be evident. Choices A, C, and D are incorrect. Disorganized behavior, specifically disorganized speech or thoughts, are symptoms associated with schizophrenia spectrum disorders, not binge eating. A primary symptom in clients with a borderline personality disorder is a fear of abandonment, partly because they do not want to be alone. This fear is not present in clients who binge eat. Perfectionism is a symptom typically associated with an obsessive-compulsive personality disorder or anorexia nervosa. Learning Objective When caring for a client who admits to binge eating, recognize the need to assess the client for depression. Additional Info ➢ Binge eating is characterized by consuming enormous amounts of food over a relatively short duration (i.e., two hours) with a feeling of losing control during and after the binge. ➢ A binging episode is not followed by an attempt to compensate for the excess food eaten (i.e., the client does not attempt to rid the body of the excessive caloric intake via purging). ➢ This condition differs from anorexia nervosa and bulimia because the individual does not purge. The individual also may have a normal BMI. However, it often increases because of the significant intake of calories. Last Updated - 27, Dec 2022

The nurse is caring for a client with narcolepsy. Which of the following medications would the nurse anticipate the primary healthcare provider (PHCP) prescribe? A. Aripiprazole B. Modafinil C. Ropinirole D. Quetiapine Submit Answer

Explanation Choice B is correct. Modafinil is a psychostimulant that is effective in treating narcolepsy. This medication promotes wakefulness and is dosed either once or twice a day. Choices A, C, and D are incorrect. Aripiprazole and quetiapine are atypical antipsychotics and not indicated in the management of narcolepsy. Quetiapine is highly sedating and would be counterproductive in the management of narcolepsy. Ropinirole is a dopaminergic and is indicated in treating Parkinson's disease and restless leg syndrome. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Expected actions/outcomes Question type: Knowledge/comprehension Additional Info Narcolepsy is a syndrome in which a client has significant daytime sleepiness that often lessens after a nap. Stimulants such as modafinil and armodafinil are indicated in the management of narcolepsy as they promote wakefulness. Common side effects of modafinil include headache, nervousness, anorexia, and weight loss. Last Updated - 28, Apr 2022

Select the psychiatric mental health disorder that is accurately paired with its signs and symptoms. A. Borderline personality disorder: Intense irrational fears and the need for orderliness and perfection B. Obsessive-compulsive disorder: The need for control, orderliness, and perfection C. Bipolar disorder: Fears of abandonment, feelings of emptiness, and unstable relationships with others D. Codependency: Fears of abandonment, a need for control, and a need for perfection Submit Answer

Explanation Choice B is correct. Obsessive-compulsive personality disorder is characterized by a pervasive preoccupation with orderliness, perfectionism, and control (with no room for flexibility) that ultimately slows or interferes with completing a task. Because clients with obsessive-compulsive personality disorder need to be in control, they tend to be solitary in their endeavors and mistrust help from others. Choice A is incorrect. A borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations, and impulsivity. Choice C is incorrect. Bipolar disorder is characterized by episodes of mania and depression, which may alternate, although many clients have a predominance of one or the other. Bipolar disorder markedly impairs the client's ability to function at work and to interact socially, and the risk of suicide is significant. Only a minimal percentage of clients alternate back and forth between mania and depression during each cycle; in most cycles, one or the other predominates. Choice D is incorrect. Codependency is characterized by the client's dysfunctional relationship with another individual, enabling dependency or addiction to substances or behaviors (i.e., alcohol, drugs, gambling, etc.). Learning Objective Identify Choice B as the correctly paired mental health disorder and description (i.e., obsessive-compulsive disorder is the need for control, orderliness, and perfection). Additional Info To maintain a sense of control, obsessive-compulsive disorder clients focus on rules, minute details, procedures, schedules, and lists. As a result, the main point of a project or activity is lost. These clients repeatedly check for mistakes and pay extraordinary attention to detail. OCD clients do not make good use of their time, often leaving the most important tasks until the end. Their preoccupation with the details and ensuring everything is perfect can endlessly delay completion. When focused on one task, these clients may neglect all other aspects of their life. Last Updated - 02, Dec 2022

You are working in a long-term psychiatric rehabilitation center and are assigned to a patient with debilitating agoraphobia. He is going through desensitization therapy. Which of the following interventions is an appropriate part of this treatment? Select all that apply. A. Speak frequently of what causes the fear to start for him. B. Take a short walk in the hallway outside of his room. C. Build rapport with the client D. Encourage him to face his fear outside where he is least comfortable. Submit Answer

Explanation Choice B is correct. Since your client has agoraphobia, they will be reluctant to leave any place they feel comfortable. Leaving the place where they feel comfortable is either unfamiliar or hard to escape from, which is why people with agoraphobia have difficulty leaving the house. The client needs to be desensitized to this fear slowly, and a short walk in the hallway outside of his room (where they feel safe) is an appropriate choice. Choice C is correct. Building rapport with the client is a fundamental part of building a trusting relationship, and building a trusting relationship with a patient going through desensitization therapy is essential. You need the client to trust you so that when you ask them to do little things outside of their comfort zone, they will be able to do them. This is the key to slow, gradual progress in desensitization. Choice A is incorrect. When treating clients with a phobia, it is not advisable to talk about what frequently causes the phobia. Although you will need to address the phobia over time, focusing on this does not help the patient desensitize. Instead, it keeps them focused on the phobia. Just speaking about their phobia can send them into a panic attack for some patients. Choice D is incorrect. The key to desensitization therapy with phobias is a gradual change over time, not a dramatic leap to facing the phobia directly. This advice would likely cause your client to have a panic attack, which would set them back considerably. Instead of suggesting that they face their phobia and jump to where he is least comfortable, start with little steps and gradually work towards those bigger goals. Last Updated - 17, May 2022

The nurse is caring for a client who has narcolepsy. Which of the following would indicate the client is achieving the treatment goals? A. Increased focus and attention. B. Decreased daytime sleeping. C. Increased daytime energy. D. Decreased social avoidance. Submit Answer

Explanation Choice B is correct. The cardinal feature of narcolepsy is daytime sleepiness, in which they may have sleep attacks that cause an individual to rapidly doze off with little warning. If a client is meeting the treatment goals, they would report decreased daytime sleeping, which would lead to increased productivity. Choices A, C, and D are incorrect. Increased focus and attention would be a treatment goal for a client with attention deficit hyperactivity disorder (ADHD). While increased daytime energy would be beneficial for an individual with narcolepsy, if the client is meeting the treatment goals, then the core feature (daytime sleepiness) would be ameliorated. Decreased social avoidance would be a treatment goal for certain personality disorders. NCLEX Category: Physiological Adaptation Activity Statement: Illness management Question type: Knowledge/comprehension Additional Info Narcolepsy is a syndrome in which a client has significant daytime sleepiness that often lessens after a nap. A client with narcolepsy may also have cataplexy, a brief emotionally triggered muscle weakness after laughter, excitement, etc. The client will then experience muscle paralysis in the face or neck. The episode typically resolves within minutes of its onset. Last Updated - 28, Apr 2022

While working in an outpatient pediatric clinic, the RN knows that as a mandated reporter it is important to monitor for suspected child abuse in all clients. The most common physical sign of child abuse is _________. A. Malnourishment B. Bruising C. Poor hygiene D. Burns Submit Answer

Explanation Choice B is correct. The most common physical sign of child abuse is bruising. The physical maltreatment of a child can manifest in many ways, but bruising is indeed the most commonly recognized physical sign that starts off the investigation. It is important to note that all nurses are mandatory reporters of abuse. If they have any suspicion that a child is being abused, they are required by law to report it. Choice A is incorrect. Malnourishment is not a sign of physical abuse, rather it is a sign of neglect. Neglect is to fail to care for properly, so if the child is malnourished and the parent is not providing them sufficient or proper nutrition, the child is being neglected. Choice C is incorrect. Poor hygiene is not a sign of physical abuse, rather it is a sign of neglect. Neglect is to fail to care for properly, so if the child is very dirty, disheveled, and clearly uncared for in the home environment, they are being neglected. Choice D is incorrect. Burns are a sign of physical abuse, but they are not the most common type. The most common physical sign of child abuse is bruising. NCSBN Client Need Topic: Psychosocial Integrity; Subtopic: Pediatrics - Abuse Last Updated - 27, Jul 2021

You have been caring for a severely depressed client in the community. When you see this client today, the client is far less depressed than they were in the past. What priority should the nurse consider in terms of this client's current psychological state? A. The client has resolved the depression. B. The client may have planned their suicide plan. C. The antidepressant medications are effective. D. Their cognitive behavioral therapy is effective. Submit Answer

Explanation Choice B is correct. The priority that the nurse should consider in terms of this client's current psychological state is the possibility that this severely depressed client has planned their suicide; this may occur when a severely depressed client becomes far less depressed than they were in the past. Although this client may be effectively treated with antidepressant medications and cognitive behavioral therapy, the priority concern is associated with a heightened risk of suicide. Choice A is incorrect. Although the client may have resolved their depression, there is a chance that this patient may be experiencing less depression because something else severe may be occurring. Choice C is incorrect. Although this client may be effectively treated with antidepressant medications, something else very serious may be occurring. Choice D is incorrect. Although this client may be effectively treated with their cognitive behavioral therapy, something else very serious may be occurring. Last Updated - 14, Dec 2021

The psychiatric nurse is providing care for a patient who has just calmed down after exhibiting inappropriate behaviors related to bipolar disorder. The nurse knows that which of the following is the best way to help prevent another unseemly episode? A. Identify the consequences of the behavior. B. Assist the client in understanding triggering events or feelings that may have lead to the outburst. C. Ensure that the patient's safety is upheld. D. Offer the patient clear options to deal with their current behavior. Submit Answer

Explanation Choice B is correct. The psychiatric nurse would be most effective in preventing further inappropriate episodes by assisting the client in understanding what may have triggered the event. Choice A is incorrect. Identifying the consequences of inappropriate behavior would be a more appropriate intervention before the patient's response began escalating. Since this patient is calm, identifying values is not the most effective option to prevent reoccurring episodes. Choice C is incorrect. Ensuring the patient's safety is intact is always a priority but is a more appropriate action during the patient's episode of inappropriate behavior rather than while the patient is calm. Choice D is incorrect. A patient experiencing an episode of inappropriate behavior related to bipolar disorder is unlikely to absorb patient teaching. Teaching is best understood when the patient is calm and states readiness to learn. NCSBN client need Topic: Psychosocial adaptation, Mental Health Concepts Last Updated - 15, Feb 2022

The nurse calls security to the parking lot of the emergency department due to an altercation between a mother and daughter. After security handles the situation, the mother is brought in for treatment. The daughter states, "I forced her to come here. She has schizophrenia and has been off her medication for two weeks now. I don't know what to do with her." What should the nurse say to the daughter to comfort her? A. "You did the right thing by bringing her here." B. "What are you concerned about related to her medication compliance?" C. "It will be okay." D. "We can get her back on her medications here and then she will be fine." Submit Answer

Explanation Choice B is correct. This is the best response for therapeutic communication with this patient's family member. It addresses the concern of the daughter and encourages her to discuss her feelings on medication compliance after leaving the hospital. Choice A is incorrect. This may be comforting for the patient's daughter to hear, but it does not address the concerns that she has about possible non-compliance after discharge. Choice C is incorrect. This is a sympathetic statement to the patient's daughter, which is inappropriate at this time. An empathetic statement should be said. Choice D is incorrect. This comforts the patient's daughter, however, it does not address the non-compliance issues in the future. NCSBN Client Need Topic: Psychosocial integrity, Sub-topic: Therapeutic Communication Last Updated - 21, Jun 2021

A widower is complaining of insomnia, shortness of breath, extreme anxiety, and a sense of impending doom. Which response by the nurse is most appropriate? A. "Just relax. You're in a safe place now. You have nothing to worry about." B. "Has anything happened recently, or is there anything in the past that could have triggered these feelings?" C. "The medication that I have given you will help decrease these feelings of anxiety." D. "Why don't you take some deep breaths to help you calm down?" Submit Answer

Explanation Choice B is correct. This response reassures the client and provides an opportunity to gain insight into the root of the client's anxiety. Choice A is incorrect. Telling the client he has nothing to worry about dismisses the client's feelings and only gives him false reassurance. By indicating to the client that there is no cause for anxiety, the nurse is thereby devaluing the client's feelings. By doing so, the nurse may inadvertently discourage the client from further verbalizing their feelings, as the client believes they will only be subsequently downplayed or ridiculed. Choice C is incorrect. Simply medicating a client and instructing them to calm down doesn't allow the client to verbalize their feelings, which is necessary for both the client and the treating health care provider (HCP) to understand and ultimately use to resolve the underlying cause of the anxiety. Choice D is incorrect. Telling the client to take some deep breaths to help calm down implies that the nurse knows what is best and that the client is incapable of any self-direction. This type of nontherapeutic communication nurtures the client into a dependent role by discouraging independent thinking and should therefore be avoided. Learning Objective When caring for a client experiencing extreme anxiety, identify the most appropriate response by the nurse as the response which reassures the client while providing an opportunity to gain insight into the root of the client's anxiety. Additional Info Therapeutic communication has demonstrated multiple clinical benefits, including improved client satisfaction, primarily by fulfilling the client's expectations and values during each encounter. Each healthcare team member plays a vital role in therapeutic communication with the client. Each team member gathers information from and subsequently communicates information to the client in various contexts.

The emergency department (ED) nurse triages a client experiencing a panic attack. The client reports nausea, chest discomfort, and a feeling of impending doom. The nurse should plan to take which priority action based on the client's symptoms? A. Assess the client for suicide B. Obtain a 12-lead electrocardiogram (ECG) C. Develop a therapeutic rapport with the client D. Inquire about the precipitating event Submit Answer

Explanation Choice B is correct. When a client is experiencing a panic attack, somatic symptoms such as hyperventilation, perspiration, chest discomfort, and nausea are likely. However, the nurse should always prioritize physical needs/reports such as chest pain. The nurse should obtain a 12-lead electrocardiogram as this is an effective way to rule out acute coronary syndrome (ACS). ACS may cause similar symptoms, such as a feeling of impending doom, and the nurse should intervene and obtain this necessary test. Choices A, C, and D are incorrect. These actions are essential. However, they do not prioritize over physical needs. The nurse should assess the client for suicide; however, the time assessing for suicide should be spent determining the physical stability of the client. Developing a therapeutic rapport would be helpful. Inquiring about the precipitating event would be unhelpful during a panic attack because clients cannot solve problems and effectively reflect. Additional Info Maslow's Hierarchy of Needs can be an effective tool in solving this item. You may recognize that physical needs are at the bottom of the framework that is because it would be ineffective to keep a client safe who is physically unstable. Thus, physical reports and needs should always come first.

The nurse is caring for a client with schizophrenia, who is speaking words and phrases that are unrelated to one another. The nurse should document this communication pattern as A. pressure speech. B. word salad C. neologism. D. clang association. Submit Answer

Explanation Choice B is correct. Word salad is a type of language and communication disturbance in which the client says words and phrases that are not indeed related to one another. Choices A, C, and D are incorrect. Pressured speech is a universal language disturbance in clients with anxiety, bipolar disorder, and schizophrenia. It appears as though the client is forcefully putting the words out. Neologism uses words that are made up of the client and have specific meanings. Clang association is a universal language disturbance where the patient speaks in rhymes or with words that sound similar but have no real meaning when strung together. Additional Info Schizophrenia symptoms are divided into positive or negative symptoms. Positive symptoms include things that add something to the client. They include: Hallucinations: Experiences involving the apparent perception of something not present. They can include any of the five senses: touch, taste, smell, sight, or hearing. Auditory hallucinations, when the client hears something that is not present, are common in schizophrenia. Delusions: Fixed, false beliefs that conflict with reality. Types of delusions include persecution, grandeur, and jealousy Thought and speech disorganization Negative symptoms are things that take something away from the client. They include: Apathy: A lack of interest, enthusiasm, or concern. Alogia: Also known as 'poverty of speech,' alogia is difficulty with speaking or the tendency to speak little due to brain impairment. Anhedonia: The inability to feel pleasure. Avolition: A total lack of motivation that makes it hard to get anything done Flattened affect

The nurse assesses a client with schizophrenia who appears to be demonstrating neologisms in their speech. Which of the following would be the expected finding? A. Words that rhyme or have a similar beginning sound B. Reduction in speech; short-worded replies C. Words or phrases with meaning only for the client D. Going off on tangents and never reaching the point Submit Answer

Explanation Choice C is correct. A neologism is when a client invents words or phrases that only have meaning for themselves. This is a positive symptom associated with schizophrenia. Choices A, B, and D are incorrect. Words that rhyme or have a similar beginning sound are a clang association (example - 'She went to the bar, and saw some tar'). A reduction of speech with short-worded replies is alogia (poverty of speech). This is a negative symptom associated with schizophrenia. Going off on tangents and never reaching the point is the classic definition of tangentially. Additional Info Schizophrenia symptoms are divided into positive or negative symptoms. Positive symptoms include things that add something to the client. They include: Hallucinations: Experiences involving the apparent perception of something not present. They can include any of the five senses: touch, taste, smell, sight, or hearing. Auditory hallucinations, when the client hears something that is not present, are common in schizophrenia. Delusions: Fixed, false beliefs that conflict with reality. Types of delusions include persecution, grandeur, and jealousy Thought and speech disorganization Negative symptoms are things that take something away from the client. They include: Apathy: A lack of interest, enthusiasm, or concern. Alogia: Also known as 'poverty of speech,' alogia is difficulty with speaking or the tendency to speak little due to brain impairment. Anhedonia: The inability to feel pleasure. Avolition: A total lack of motivation that makes it hard to get anything done Flattened affect Last Updated - 03, Aug 2022

A client is scheduled to undergo electroconvulsive therapy (ECT). The nurse understands, which action needs to be performed prior to the ECT? A. Assess the client for contrast dye allergy. B. Administer an anti-convulsant. C. Apply a blood pressure cuff to the client's arm. D. Check if the client is on Metformin. Submit Answer

Explanation Choice C is correct. ECT procedure involves administering an electric current to create a generalized seizure. Prior to this, the client is given intravenous sedation or general anesthesia. Anesthetic/sedative medications such as barbiturates (thiopental, methohexital), propofol, and etomidate are often used. In addition, a neuromuscular blockade agent (succinylcholine) is also used to reduce the risk of physical injury that may result from unopposed tonic-clonic muscle contractions during a seizure. During the procedure, one should continuously monitor the vital signs, oxygen saturation, ECG, EEG (electroencephalogram) activity as well as, motor component of the seizure activity. But because of the neuromuscular blockade agent (NMBA) used during anesthesia/sedation, one cannot readily appreciate the motor activity of the seizure. In order to monitor whether electrical stimulation has produced a tonic-clonic seizure, a blood pressure (BP) cuff is wrapped around an ankle or arm and is inflated above systolic pressure before the NMBA is injected. This prevents NMBA from entering that foot or arm allowing the provider to visually observe the motor component of seizure activity in that foot/arm. Choice B is incorrect. The client is given intravenous sedation or general anesthesia before ECT. ECT involves inducing a cerebral seizure. Anticonvulsants should not be used. Choice A is incorrect. The nurse does not need to assess the client for allergies to contrast dye. Iodinated contrast agents are not used during ECT. Choice D is incorrect. While the medication list needs to be checked, there is no particular reason to give specific attention to metformin prior to the ECT. The nurse does not need to stop metformin prior to the ECT. Metformin should be held prior to administering intravenous contrast dye. ECT does not involve administering IV contrast. Last Updated - 03, Feb 2022

The son of a client with early Alzheimer's disease states, "I'm so tired of hearing Dad talk about the past all the time." What is the nurse's best response? A. "You should be more patient with your father and accepting of his disease." B. "He is quite anxious at this stage. Reliving the past helps him become calm again." C. "He has lost his short-term memory but can still remember events from long ago." D. "Just remind him when he repeats himself and that will reinforce better behavior." Submit Answer

Explanation Choice C is correct. Family members can become frustrated when clients with Alzheimer's disease lose short-term memory. The nurse should explain to the family member that it's the "short-term memory" that is declining and encourage the client to talk about things that he/she can remember. Choice A is incorrect. During the early stages of Alzheimer's, family members are still trying to learn about and cope with the changes that their loved ones are experiencing. Patience with the family will be more beneficial than the scolding tone that this answer choice portrays. Choice B is incorrect. Early Alzheimer's symptoms are not usually reflective of anxiety. Also, the client is not reliving past experiences because it makes him calm again. Instead, his behavior is expected as Alzheimer's first affects short-term memory. Choice D is incorrect. Reminding an Alzheimer's patient that he is repeating himself will not improve the behavior as his short-term memory is affected. The hippocampus is the structure responsible for creating new memories from experiences. When it is damaged, short-term memory is not possible. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Promoting Health in Older Adults, Cognitive Abilities and Aging Last Updated - 30, Jul 2021

The nurse is assessing a client suspected of having the early stages of dementia. Which defense mechanism would the nurse expect? A. Identification B. Projection C. Denial D. Conversion Submit Answ

Explanation Choice C is correct. In the early stages of dementia, it is quite common for family members and the client to exhibit denial. Denial is utilized to avert the unpleasant emotions surrounding the diagnosis of dementia which is progressive in terms of its symptom intensity. Typically, symptoms that may be concerning for dementia are noticed by family or friends. This individual (an informant) usually brings this concern forward to the primary healthcare provider (PHCP). Choices A, B, and D are incorrect. Identification is attributing to oneself the characteristics of another person or group. This is not seen in the early part of dementia, as complete avoidance of memory loss is exhibited. Projection is unconsciously rejecting emotionally unacceptable features and attributing them to others. This is not seen in dementia as the client rarely projects their memory impairments onto others. Conversion is not a feature of this disorder because the client is not taking their psychological symptoms and putting them into physical ones that cannot be explained organically. Additional Info Clinical Features of Dementia The incidence and prevalence of dementia increase exponentially with age, essentially doubling in prevalence every 5 years after the age of 65 years. Insidious onset Poor prognosis as the disease is progressive. Idiopathic; however, uncontrolled hypertension and diabetes contribute to vascular dementia. Attention is unimpaired in the early part of the disease process Memory impairments start with recent memory and then impact remote memory Difficulty with judgment and executive functioning No alteration in consciousness The flat affect that may progress to behavioral disturbances such as agitation

The nurse is educating a new graduate nurse on different forms of therapeutic communication. Select the form of therapeutic communication which is accurately paired with the correct description of that form of therapeutic communication. A. Seeking Clarification: Utilizing open-ended questions rather than closed-ended questions B. Offering General Leads: Ensuring the client fully understands the sent message C. Reflection: By repeating the client's words back to the client, the nurse conveys that they are actively listening while concurrently encouraging further expression from the client D. Offering Self: Giving the client advice based on the opinion of the nurse Submit Answer

Explanation Choice C is correct. Reflection is a way of helping clients better understand their thoughts and feelings. By utilizing a question, simple statement, or the client's own words, the nurse may convey their observations of the client. Choice A is incorrect. Utilizing a seeking clarification therapeutic communication technique does not limit a nurse to only using open-ended questions, nor forbid them from using closed-ended questions. The goal of this therapeutic communication technique is to make clear that which is vague or maximize understanding between the nurse and client. A number of clarification techniques (i.e., paraphrasing, open-ended questions, closed-ended questions, reflecting, restating, etc.) may be used to achieve this goal when seeking clarification. Choice B is incorrect. When offering general leads, the nurse allows the client to take direction in the discussion. By using phrases such as "go on" or "and then?" the nurse conveys interest in what occurs next in the client's story. Choice D is incorrect. Hospital stays can be lonely and stressful at times. When nurses are present with their clients, it shows clients that the nurses value them and are willing to provide them time and attention. The mere offering by a nurse to be present with a client for a few minutes is a powerful way to create a caring connection. Learning Objective Recognize the therapeutic communication technique of reflection in which the nurse repeats the client's words to the client to demonstrate active listening while concurrently encouraging further expression from the client. Additional Info The forms of communication listed above (i.e., seeking clarification, offering general leads, reflection, and offering self) are all techniques used to enhance communication. When appropriately used, silence, active listening, and clarifying techniques are valuable tools for nurses when communicating with clients.

Which of the following represents appropriate nursing documentation of a patient with a normal mood? A. Sad and tearful during conversation B. Grandiose or strongly confident C. Pleasant or appropriate to the situation D. Tearful but mildly humble and meek Submit Answer

Explanation Choice C is correct. The mood is a sustained emotion. Nurses should assess the intensity, depth, and duration of an altered climate. Patients may describe feeling happy, excited, sad, tearful, depressed, angry, anxious, or fearful. When assessing a patient's climate, it is essential to listen to verbal cues but also observe for nonverbal cues. For example, if the patient states, "I am happy," but she seems nervous or is crying, the nurse should document the objective data, as well. Choices A, B, and D are all incorrect. These answer choices reflect abnormal moods, which are described as sad, tearful, depressed, angry, anxious, grandiose, and fearful. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Mood and Behavior Last Updated - 08, Nov 2021

A client diagnosed with an anxiety disorder is at a local mental health clinic. Due to the number of people coming and going through the clinic, the client suddenly suffers an acute anxiety attack. The nurse in the clinic would initiate which nursing intervention initially? A. Give one tablet of alprazolam immediately. B. Talk to the client and explore his feelings. C. Accompany the client to a vacant room and let him rest. D. Take the client's vital signs. Submit Answer

Explanation Choice C is correct. The most appropriate initial intervention is for the nurse to remove the client from the stressful situation and let him rest. This will help decrease the anxiety of the client. Choice A is incorrect. Giving the client medication does not remove the stressor. Furthermore, most anxiolytics will take at least 30 minutes to take effect. Choice B is incorrect. The nurse may be unable to talk to the client as he is still anxious and cannot collect himself. This is not the most appropriate initial action for the nurse to take. Choice D is incorrect. The nurse should remove the client from the stressful situation first, then assess his vital signs. Last Updated - 18, Jan 2022

A woman is brought to the ER crying and shocked. She tells the nurse that she has just been raped. What should be the nurse's initial action? A. Notify the police B. Call the sexual assault nurse examiner to see the client C. Assess her for injuries D. Assist the client in completing the admission form Submit Answer

Explanation Choice C is correct. The nurse should address the client's physiological needs first and then facilitate the necessary processes to deal with the rape. Choice A is incorrect. The client may want to notify the police, but the nurse should prioritize her physiological needs first then report the incident. Choice B is incorrect. The sexual assault nurse examiner (SANE) is a nurse specialized in caring for clients that have been raped. They are knowledgeable in dealing with clients who have been raped and are familiar with the legal proceedings. Before notifying the SANE, the nurse should first address the client's physiological needs. Choice D is incorrect. The nurse should prioritize care for the client over admission forms. The client can accomplish the admission forms after being treated. Last Updated - 03, Feb 2022

The nurse is caring for a client who is experiencing psychosis. The client states, "You all are trying to kill me!" Which of the following responses would be most appropriate for the nurse to make to the client? A. "What you are experiencing is not real." B. "Are you hearing voices?" C. "You are safe here, please be calm." D. "What makes you think we are trying to kill you?" Submit Answer

Explanation Choice D is correct. A client experiencing psychosis does not exhibit a rational thought process and may have impaired reality testing. If the client is paranoid, the nurse should attempt to understand the paranoia as the patient has likely misconstrued an action. Choices A, B, and C are incorrect. While it is essential to inquire if the client is experiencing auditory hallucinations and reassure them that their thought is not real, it is a priority to understand the delusion by inquiring about its root. Reassuring safety is important but will not inquire about a patient's current thought process. Additional Info When caring for a client experiencing psychosis, the nurse should avoid physical contact with the client, maintain a safe environment, and reorient the patient to reality without being argumentative. Last Updated - 26, Apr 2022

While rounding in the mental health unit, you are learning about specific phobias. You should be aware that ailurophobia is an unreasonable fear of: A. Social interactions B. Clowns C. Crowds D. Cats Submit Answer

Explanation Choice D is correct. Ailurophobia is best described as an unreasonable fear of cats. The psychiatric mental health treatment interventions for phobias are based on the specific type of phobia. For example, ailurophobia is usually treated with exposure therapy to the object or situation that is causing this unreasonable fear. Choice A is incorrect. A fear of social interactions is referred to as a social phobia. Social interaction phobias are typically treated with exposure therapy, antidepressants, or beta-blockers. Choice B is incorrect. The fear of clowns, which is referred to as coulrophobia, is typically treated with exposure therapy. Choice C is incorrect. The fear of crowds, which is referred to as enochlophobia, is also typically treated with exposure therapy. Last Updated - 17, Jun 2021

In which age group is child abuse most likely to occur? A. Ten-years-old or older B. 6-10 years old C. 4-6 years old D. Birth-3 years old Submit Answer

Explanation Choice D is correct. Children between birth and three years of age have the highest incidence of victimization. The current rate is approximately 16 in 1,000 children. Also, the impact is higher in girls than in boys. Child abuse crosses all cultures, ages, economic levels, races, and religions, but is most prevalent in families living in poverty and those families composed of adolescent parents with young children. Nurses should never make assumptions about certain groups being at higher risk for child abuse but rather should be aware that social, economic, and personal stressors can contribute to the incidence of child abuse. Acts of commission in child abuse are situations in which the responsible person, often the parent, intentionally harms the child via physical, emotional, or sexual abuse. Acts of omission in child abuse are situations in which a parent or caregiver, to their best of abilities and often inadvertently, cannot provide adequate nutrition, shelter, warmth, appropriate seasonal clothing (e.g. winter coats), safety, and education for his or her child. Both are considered significant categories of child abuse, and situations identified in both groups must be reported. The idea of responding to both acts of commission and acts of omission is to provide safety for the child or provide what is necessary for the child to thrive and grow in a safe environment. Choices A, B, and C are incorrect. Although child abuse can occur at any age, it is most prevalent in younger populations, like those in answer choice D. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Child Abuse and Prevention Last Updated - 02, Feb 2022

Crisis helplines are highly important due to which of the following? A. Facilitates the ability of the nurse to visit the home. B. Allows the caller and the call center to plan follow-up care. C. Serves as a cost free way to develop new coping strategies. D. Often saves lives when a person is in a severe crisis. Submit Answer

Explanation Choice D is correct. Crisis helplines are highly relevant because these helplines often save lives when a person is in a severe crisis. These helplines are staffed with people who use somewhat scripted verbal communication that addresses the here and now of the crisis. The caller can remain anonymous if they choose to do so. They are also allowed to solve their immediate problem and be able to cope with their stressors in the crisis. Choice A is incorrect. Call centers for crises do not facilitate a visit to the person's home, but they do provide other needed help. When necessary, they may call for help to the person's house when the client's life is in danger. Choice B is incorrect. Although these call centers allow the caller and the call center to remain on the line, follow-up care is encouraged, but it is not planned. Choice C is incorrect. Crisis call lines are free of cost, but these lines are not intended to help the client to develop new coping strategies; this is done during the follow-up to the immediate crisis. Last Updated - 15, Feb 2022

Which of the following statements indicates body image distortion in a patient with anorexia nervosa? A. "I wish I looked like my mom." B. "I hate how my body looks." C. "I wish I could wear tank tops." D. "I'm so overweight." Submit Answer

Explanation Choice D is correct. Patients with anorexia perceive themselves to look differently than they do. Many of these patients see someone in the mirror who weighs more than their desired weight. Despite being too thin, this client will not eat in hopes of getting the perfect body. Choices A, B, and C are incorrect. Although these are signs of altered body image, these statements do not reflect body image distortion. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Factors Affecting Self-Perception Last Updated - 27, Oct 2021

Your client is affected by nightmares, flashbacks to a previous event, and intrusive, threatening thoughts. Which disorder is this client most likely experiencing? A. Panic disorder B. A phobia C. Anxiety disorder(s) D. Post-traumatic stress disorder Submit Answer

Explanation Choice D is correct. Post-traumatic stress disorder (PTSD) is characterized by ongoing and unyielding nightmares, flashbacks to a previous event, and intrusive, threatening thoughts. Post-traumatic stress disorder occurs primarily among those who have witnessed and/or been exposed to a severe traumatic event (i.e., warfare, rape, witnessing a murder, etc.) likely to invoke feelings of fear, helplessness, or horror in the individual who witnesses the event. Choice A is incorrect. A panic disorder occurs when the client experiences repeated panic attacks, typically accompanied by fears about future attacks or changes in behavior to avoid situations that might predispose the client to additional attacks. Choice B is incorrect. A phobia is a fear of and/or anxiety regarding a particular situation or object to a degree that is out of proportion to the actual danger or risk. Contact with the situation or object is usually avoided when possible, but if exposure occurs, anxiety quickly develops. Choice C is incorrect. The term "anxiety disorders" is a broad umbrella term encompassing numerous anxiety-related psychiatric disorders, including, but not limited to, agoraphobia, generalized anxiety disorder, acute stress disorder, social phobia, post-traumatic stress disorder, etc. Anxiety disorders are characterized by varying degrees of generalized anxiety ranging from mild to severe. Treatments vary based on the client's specific anxiety disorder(s), but typically involve a combination of psychotherapy specific for the disorder and medication therapy treatment (most commonly benzodiazepines and/or selective serotonin reuptake inhibitors (SSRIs)). Clients with an anxiety disorder are more likely than other individuals to experience depression. Although post-traumatic stress disorder is included under the umbrella term of anxiety disorders, this is not the best answer to this question. Learning Objective When evaluating a client affected by nightmares, flashbacks to a previous event, and intrusive, threatening thoughts, identify post-traumatic stress disorder (PTSD) as the disorder this client is most likely experiencing. Additional Info Symptoms of post-traumatic stress disorder can be subdivided into categories: intrusions, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. Diagnosis is based on history. Treatment often consists of exposure therapy and/or drug therapy (most commonly, selective serotonin reuptake inhibitors (SSRIs)). Many post-traumatic stress disorder clients also experience survivor's guilt. Last Updated - 16, Dec 2022

A nurse cares for a client who has missed their last appointment with the primary healthcare provider (PHCP). The client states, "I missed my appointment because I overslept, but I knew it would be pointless anyway." The client is demonstrating which defense mechanism? A. Projection B. Reaction formation C. Denial D. Rationalization Submit Answer

Explanation Choice D is correct. Rationalization is a higher-level defense mechanism that involves an individual justifying behavior that is often offensive or abnormal through statements that they believe provide validation. However, rationalizing the behavior is done to avoid authentic feelings such as guilt if they have done something wrong. The client missing their appointment because they overslept is rationalizing this choice because they perceived the appointment as pointless. Choices A, B, and C are incorrect. The client is not demonstrating projection because they are not attributing their unacceptable feelings and thoughts to someone else. Reaction formation is when an individual acts opposite to their true feelings or actions. Denial is not exhibited because the client is acknowledging the missed appointment. Denial is when individuals block situations because they refuse to embrace the situation and associated emotions. Additional Info Defense mechanisms are employed to protect the ego. These mechanisms may be overused, and that may suggest a personality disorder. The nurse should be aware of defense mechanisms and understand that they are often executed when a client is experiencing anxiety. Last Updated - 03, Dec 2022

A nurse is caring for a woman who will undergo electroconvulsive therapy (ECT) for the first time. Her husband asks the nurse if he could visit his wife on her ECT treatment days and voiced out concerns regarding what he should expect after the initial treatment. The nurse's best response is: A. "Are you sure you'd like that? They are pretty sick after the first treatment, and you'll have to get permission from the physician to visit." B. "Visitors are prohibited. We will just telephone you to update you of her progress." C. "She will be asleep for several hours after the treatment. There's really no need to stay there." D. "Yes, you may visit her. She may have temporary drowsiness, confusion, or memory loss after each session." Submit Answer

Explanation Choice D is correct. The nurse discusses visiting privileges according to hospital policy. For ECT treatments, visitors are allowed and encouraged, particularly family members. ECT treatments do not make clients sick, and they are usually awake an hour after the surgery. As the anesthetic wears off, the client's drowsiness also wanes. "Yes, you may visit her. She may have temporary drowsiness, confusion, or memory loss after each session," is the best response as it allows the nurse to alleviate fears by explaining the temporary side effects of the treatment. Choices A, B, and C are incorrect. These are nontherapeutic responses. Last Updated - 13, Oct 2021

While conducting a class for new graduate nurses working on the psychiatric unit, one of the new graduate nurses asks you to elaborate on the term "therapeutic milieu." Which of the following responses most accurately describes a therapeutic milieu? A. "'The treatment for depression where the client is given a short-acting anesthetic, and a small amount of electric current is delivered, causing a small seizure to occur." B. "The ability of a client to learn new skills by imitating another person, typically the therapist, allowing the client to learn through imitation." C. "The use of incentives, motivation, and rewards to help clients control their symptoms to facilitate the development of better coping skills in the clients." D. "A 'therapeutic milieu' is a healthy social structure within an inpatient setting or structured outpatient clinic. Within these small versions of society, individuals are safe and increase their ability to interact with the outside community." Submit Answer

Explanation Choice D is correct. The term "therapeutic milieu" is used in psychiatric units to describe the planned and therapeutic elimination of all triggers and stressors within the unit to facilitate the client's development of better coping skills. Additional information on this topic is included in the table below. Choice A is incorrect. In this statement, the new graduate nurse is describing electroconvulsive therapy (ECT), not a therapeutic milieu. Additional information on electroconvulsive therapy is included in the table below. Choice B is incorrect. The statement provided in Choice B describes modeling. Modeling facilitates the client's ability to mimic and copy acceptable behaviors. It is perhaps one of the most potent means of value education, as it presents a vivid example of values in action. Additional information on modeling is provided in the table below. Choice C is incorrect. This graduate nurse is describing behavior modification. In behavior modification, the health care team attempts to correct or eliminate maladaptive behaviors or responses by rewarding and reinforcing adaptive behavior. Please see the table below for additional information on behavior modification. Learning Objective Analyze the statements provided to determine which statement best describes the meaning of "therapeutic milieu." Additional Info Last Updated - 30, Jul 2022

You are working with a patient who suffers from obsessive-compulsive disorder (OCD). They are obsessed with the dangers of germs and compulsively wash their hands hundreds of times per day. Their skin has become red and raw. Which of the following should be included in the treatment plan for this patient? Select all that apply. A. Create a schedule for the hand washing ritual. B. Teach them about the dangers of over washing their hands. C. Add time for meditation to their daily schedule. D. Remove the sink from their room so they are unable to wash their hands. Submit Answer

Explanation Choices A and C are correct. Creating a schedule is one of the most critical aspects of treatment for patients with obsessive-compulsive disorder (OCD). In this schedule, it is essential to allow time for their compulsive ritual. This may sound counterintuitive, but not allowing any time for the ritual will dramatically increase their anxiety. This will not be therapeutic. Instead, we must gradually decrease the amount of time which they are allowed to practice the ritual (for example, only washing hands for 5 minutes at a time rather than 10 minutes), and increase the amount of time left between the ritual (for example, waiting 1 hour between hand washings instead of just 10 minutes) (Choice A). Adding time into the daily schedule for meditation is an appropriate intervention. Meditation is an excellent coping mechanism that the client can learn. This can be added in to replace some of their handwashing. Gradually they can spend more and more time practicing meditation and other appropriate coping mechanisms, and less and less time performing the ritual of handwashing (Choice C). Choice B is incorrect. Teaching the client about the dangers of over washing their hands will not be practical or therapeutic. This client is using the ritual of handwashing unconsciously to relieve their anxiety. They are not able to stop and will not be any more inclined to stop if they know it is terrible for them. Choice D is incorrect. Not allowing any time for the ritual is not an appropriate action for the patient with OCD. It is essential to allow time for their compulsive ritual. Not allowing any time for the behavior will dramatically increase their anxiety. This will not be therapeutic. Instead, we must gradually decrease the amount of time which they are allowed to practice the ritual (for example, only washing hands for 5 minutes at a time rather than 10 minutes), and increase the amount of time left between the ritual (for example, waiting 1 hour between hand washings instead of just 10 minutes). The ritual should never be taken away without replacing it with appropriate coping mechanisms. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Psychiatric Nursing Last Updated - 01, Dec 2021

When assessing a 2-year-old patient for potential neglect. Which of the following signs should the nurse assess for? Select all that apply. A. Height and weight B. Bruising C. Developmental milestones D. Temperature Submit Answer

Explanation Choices A and C are correct. The nurse should assess the child's height and weight to evaluate for potential neglect. A child who has been neglected will likely fall behind the growth and development of other children their age. Their height and weight should be plotted on the growth chart specific to their age and sex to determine where they fall. If they are steadily falling behind, it could be a physical sign of their neglect (Choice A). The nurse should assess the child's development to evaluate for potential neglect. A child who has been neglected will likely fall behind in both the growth and development of other children their age. For example, developmental milestones that the average two-year-old should achieve include: knowing the names of body parts, saying 2-4 word sentences, building towers of 4 or more blocks, kicking a ball, running, and walking up/downstairs. A child who has been neglected may be falling behind in these milestones (Choice C). Choice B is incorrect. Bruising is not a sign of neglect. The definition of negligence is to fail to care for properly. The child who is being neglected might be left at home alone unsupervised, not given adequate food and nutrition, not being taken to their pediatrician, behind on their vaccination schedule, and more. The definition of abuse, on the other hand, is to treat a person with cruelty or violence. This could include physical abuse, where a child may show bruising. Choice D is incorrect. The child's temperature will not help the nurse assess for neglect. A fever could indicate an illness, but would not assist in determining negligence. The nurse should assess the child's physical appearance, height, weight, and developmental milestones. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Pediatrics - Abuse & Neglect Last Updated - 12, Nov 2021

You are putting together a community health presentation about the signs and symptoms of depression to promote awareness of the disease and educate the public. Which of the following signs and symptoms would be essential to include? Select all that apply. A. Anhedonia B. Flight of ideas C. Looseness of associations D. Sleep disturbances Submit Answer

Explanation Choices A and D are correct. Anhedonia is a common symptom of depression. It is defined as the loss of pleasure in usually pleasurable things. For example, a mother who usually loves going to see her children in their dance recitals says she no longer wants to go. The things that once brought someone joy do not do that anymore due to depression. This can be difficult for families to understand and can cause a lot of frustration. You should educate your community that this is not the patient's fault, but a part of the disease process of depression (Choice A). Sleep disturbances are an incredibly common symptom of depression and should undoubtedly be a point of education. In patients suffering from depression, their sleep disturbances usually occur when they wake up in the middle of the night and are unable to go back to sleep. In patients suffering from anxiety, there are also significant sleep disturbances, but the trouble is usually falling asleep rather than staying asleep (Choice D). Choice B is incorrect. Flight of ideas is not a typical symptom of depression, but rather mania. Flight of ideas is defined as "a rapid shifting of ideas with only superficial associative connections between them that is expressed as a disconnected rambling from subject to subject." It is tough to have a coherent conversation with someone who is experiencing a flight of ideas because they jump from topic to topic so quickly. It is common that this symptom of mania presents in the manic phases of bipolar disorder, but not in depression alone. Choice C is incorrect. Looseness of associations is a common symptom of schizophrenia, but not of depression. Looseness of associations is defined as "speech that is disconnected and fragmented, with the individual jumping from one idea to another unrelated or indirectly related idea." People who have schizophrenia often have disorganized thoughts and are unable to communicate those thoughts to others in a coherent manner. This is not usually the case with a patient experiencing depression. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Psychiatric Nursing Last Updated - 30, Jan 2022

The nurse is assessing a client with Dependent Personality Disorder. Which of the following would be an expected finding? Select all that apply. A. Difficulty with decision-making B. Flamboyant behaviors C. Intense and unstable relationships D. Avoiding social relationships E. Feels helpless when alone Submit Answer

Explanation Choices A and E are correct. Individuals with Dependent Personality Disorder manifest difficulty with decision-making and initiating projects. Choices B, C, and D are incorrect. Flamboyant behaviors and provocative dressing is a hallmark characteristics of histrionic personality disorder. Intense and unstable relationships are a cardinal manifestation of Borderline Personality Disorder. Finally, avoiding social relationships and situations is a finding with Avoidant Personality Disorder. Additional Info Dependent Personality Disorder is a personality disorder characterized by difficulty with making decisions, problems with expressing disagreement, and often feeling helpless when alone. The nurse should encourage decision-making but never make decisions for the client. Last Updated - 18, Nov 2022

The nurse is caring for a client who reports a sexual assault. Which actions should the nurse take? Select all that apply. A. Interview the client in a private room B. Refer the client to support groups C. Allow the client to be alone to promote problem-solving D. Record verbatim statements in the medical record E. Repeat questions previously answered Submit Answer

Explanation Choices A, B, and D are correct. When caring for a client who has been sexually assaulted, the nurse must maintain a private environment to allow the client to be forthcoming with their answers. Support groups are quite influential in the recovery process, and it would be wise for the nurse to provide these at discharge. Recording verbatim statements in the medical record are necessary because the nurse must construct an accurate nursing note. The nursing note may also be subject to legal proceedings, reinforcing the necessity for accurate documentation. Choices C and E are incorrect. Following a sexual assault, the client should not be left alone. This crisis may produce emotional lability that requires therapeutic guidance from the nurse. This traumatic episode may be painful, and repeating previously answered questions should be minimized to promote client comfort. It would be helpful for the nurse to conduct the assessment with the medical provider to help minimize further trauma. Additional Info ✓ Caring for a victim of a sexual assault requires unyielding compassion to assist the client through the crisis. ✓ The nurse should maintain a private environment for the interview and examination. ✓ Plan to assess the client with the medical team to minimize repetitive questions and assessments which may further traumatize the client ✓ Do not leave the client. ✓ Reinforce to the client that they are not to blame ✓ Outpatient referrals to support groups are essential in the recovery process ✓ Referrals may include psychiatry or therapy Last Updated - 12, Jan 2023

The nurse is caring for a client with Borderline Personality Disorder. Which of the following actions should the nurse take? Select all that apply. A. Assess the client for suicidal ideation B. Encourage independent decision-making C. Establish therapeutic boundaries D. Refer the client for group therapy E. Encourage social relationships Submit Answer

Explanation Choices A, C, and D are correct. Individuals with Borderline Personality Disorder (BPD) often engage in self-harm/parasuicide behaviors in which the intent is not death. These gestures may be superficial cutting, etc. All clients should be assessed for suicide regardless of their diagnosis. Therapeutic boundaries should be established as a characteristic of this personality disorder is polarizing individuals and splitting. Referring the client for group therapy is one of the cornerstone treatments for BPD. Choices B and E are incorrect. Independent decision-making is not impaired for an individual with BPD. This would be an intervention for Dependent Personality Disorder. Finally, the client with BPD can establish social relationships - although they may be unstable, this would be an intervention for Avoidant Personality Disorder. Additional Info Borderline Personality Disorder occurs more in females than males and has features such as self-harm/parasuicidal behavior, splitting, unstable relationships, an unclear self-image, and impulsivity. Last Updated - 03, Sep 2022

Which of the following findings would lead you to suspect non-accidental trauma in your 1-year-old burn victim patient? Select all that apply. A. Scalding on the anterior trunk B. Circumferential burns on the feet C. Same thickness of skin damage throughout the burn D. Burns to the soles of the feet Submit Answer

Explanation Choices B and C are correct. B is correct. Circumferential burns on the feet would lead you to suspect non-accidental trauma in a 1-year-old. As a mandatory reporter, you are required to report these suspicions. Circumferential burns are full-thickness burns affecting the entire circumference of an area. They are very dangerous and can cause serious complications. In this case, it is unlikely a one-year-old could inflict a circumferential burn of the feet to themselves accidentally. This burn pattern can be caused by holding the child's feet in scalding water. C is correct. A burn that has the same thickness of skin damage throughout the burn is suspicious for non-accidental trauma. In an accident where something such as boiling water was spilled, the water will cool as it moves and leaves different levels of tissue damage in different areas. Likewise, if the child splashes in a bathtub with water that is too hot, areas will be affected differently. If the burn has the same thickness of skin damage throughout, it is suspicious for being non-accidental. Choice A is incorrect. It is more likely for a 1-year old to spill something on their anterior trunk accidentally. If they pull down on anything, such as a pot on the stove, it can spill onto their torso and burn them. Burns on the posterior surface of a one-year-old would be suspicious for non-accidental trauma. Choice D is incorrect. Burns to the soles of the feet are not necessarily a concern for non-accidental trauma. The child could have stepped onto something hot causing the burns accidentally. Areas of suspicion should include the back, buttocks, inside of the thighs, and genitalia. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Pediatrics - Integumentary Last Updated - 23, Dec 2021

The nurse cares for a client with major depressive disorder (MDD). Which of the following would indicate that the client is achieving the treatment goals? Select all that apply. A. Reporting a decreased appetite. B. Engaging in daily exercise. C. Increasing social ties. D. Drinking alcohol with friends. E. Not attending therapy sessions. Submit Answer

Explanation Choices B and C are correct. A client engaging in daily exercise and increasing their social ties are significant strides in meeting the treatment goals. A client engaging in exercise decrease their neurological inflammation and exposes themselves to light, which is quite helpful in treating MDD. Loneliness is a significant risk factor for depression and by a client increasing their social ties, they are engaging with others and strengthening their ability for self-expression. Choices A, D, and E are incorrect. Changes in appetite (less or more) are symptoms consistent with MDD. Thus, this would not indicate a client meeting the treatment goals. Drinking alcohol is a maladaptive coping mechanism regardless of other individuals. Alcohol causes disinhibition and may lead to a client harming themselves. Therapy is a highly effective adjunct in the treatment of MDD. Thus, a client must attend prescribed sessions as part of the treatment plan. Additional Info MDD is a significant medical condition that is a burden on both the individual and the healthcare system. The acronym of SIGECAPS can recall the symptomology of MDD. · S sleep disturbances · I interest decreased · G guilt or feeling of worthlessness · E energy is decreased · C concentration is impaired · A appetite disturbances · P psychomotor retardation or agitation · S suicidal ideations Establishing a therapeutic rapport with the client is essential. The nurse should encourage gentle socialization, exercise (or exposure to natural light), education on sleep hygiene measures, and adherence to prescribed treatments. Last Updated - 06, Nov 2022

Which of the following statements would be effective therapeutic communication for a client who is struggling with severe depression? Select all that apply. A. "Great work today in group therapy Steve, you were really talkative today!" B. "I'd like to just sit with you for a while Steve." C. "Tell me how you're feeling Steve. I'd like to understand." D. "Why are you feeling depressed today Steve?" Submit Answer

Explanation Choices B and C are correct. The therapeutic communication technique of silence is very effective with patients in the severe phase of depression. These patients have very little, if any, energy. Making absolutely no demands or requests of them, but being present and supportive, is often the best way to begin a therapeutic relationship (Choice B). They often feel helpless and as if no one understands the pain that they are going through. Asking them open-ended questions and letting them know you want to understand what is going on will encourage them to express their feelings and begin to work towards recovery (Choice C). Choice A is incorrect. Although this sounds like an encouraging thing to say, compliments are not always therapeutic in patients suffering from depression. They have very little to no self-esteem and often take compliments the wrong way. Even though you meant to encourage Steve by telling him he was talkative, he will likely take this as saying he was talking too much and should be quieter next time. Choice D is incorrect. "Why" statements are not therapeutic. This points the finger at the client and makes them feel as if it is their fault they are having these feelings. Asking 'why' someone feels the way they do invalidates them, and will not promote the open and honest communication that is necessary for a therapeutic environment. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Psychiatric Nursing Last Updated - 10, Nov 2021

The nurse is developing a plan of care for a client admitted to the mental health unit with significant paranoia. Which of the following should the nurse include in the client's plan of care? Select all that apply. A. Plan competitive activities with other clients. B. Maintain consistent caregivers. C. Establish a rapport using therapeutic touch. D. Involve the client in decision-making. E. Develop a plan of care that is unstructured. F. Immediately enroll the client in group therapy. Submit Answer

Explanation Choices B and D are correct. A client experiencing paranoia may be very conspiratorial, and while it is important to reinforce reality, it would be appropriate to acknowledge their feelings. Involving the client in the decision-making process and avoiding any surprises is essential. Consistent caregivers are recommended because this cements the therapeutic relationship with staff. Choices A, C, E, and F are incorrect. Activities should be structured and non-competitive. Competition may enable hostility and decrease a client's self-esteem. Central to caring for a client experiencing paranoia is having a therapeutic relationship without touch. Touch may be misinterpreted and should not be used. The same may be said for direct eye contact. Direct eye contact may raise an individual's suspicion. The plan of care should always be structured and verbalized to the client. This reinforces a trusting relationship. While group therapy may be helpful, this should be done gradually and not right away. Individuals with paranoia may initially resist socialization. Additional Info For a client experiencing paranoia, developing trust with the client may be difficult. Establishing a trusting relationship that does not involve therapeutic touch is important as this may be misinterpreted. Avoiding eye contact is also beneficial because direct eye contact may be misinterpreted. If the client is concerned about poisoned food, provide prepackaged foods. Avoid talking in front of the client and avoid any secretive activities. It would be beneficial to establish a very clear schedule of the tasks ahead and establishes trust and expectations. While group therapy may be helpful, this should be done gradually as the client experiencing paranoia will likely resist socialization.

You are taking care of a 12-year-old boy in the PICU admitted after a suicide attempt. He ingested multiple pills from his mother's medicine cabinet, some of which were oxycodone. He was found down and successfully resuscitated after 10 minutes of CPR. When doing your admission assessment, you notice several scars as well as open cuts on his wrists. What are the appropriate ways to respond to these findings? Select all that apply. A. Talk with his parents and inform them this is not acceptable. B. Ask him directly how he got these cuts. C. Tell him that he should never harm himself again. D. Speak with the patient in a nonjudgmental manner to understand what he feels has happened. Submit Answer

Explanation Choices B and D are correct. It is essential to address the issue directly. If the nurse does not bring up the problem, the patient will likely try to avoid it (Choice B). It is essential to speak to this patient in a non-judgmental way. This allows the patient to open up and discuss their feelings. They may tell you why they have participated in self-harm activities, allowing you to begin to help them (Choice D). Choice A is incorrect. Telling his parents is not the appropriate nursing action. This does not deal with the issue directly and may cause the patient not to trust the nurse with their true feelings. Choice C is incorrect. Telling the patient not to harm himself again is not therapeutic communication. This negates the patient's feelings and does not help him in any way. NCSBN Client Need: Topic: Psychosocial adaptation Subtopic: Mental health concepts Last Updated - 29, Jul 2021

What health issues might you expect to find in a client that is a victim of domestic violence? Select all that apply. A. Upper respiratory infections B. Bruises and broken bones C. Unintended pregnancies D. Repetitive strain injuries E. Alcoholism F. Depression Submit Answer

Explanation Choices B, C, E, and F are correct. Domestic violence (including physical, emotional, and sexual abuse) occurs throughout society. It is present among all racial, social, and economic groups. Health issues related to domestic violence include physical injury from the assault and chronic health problems that may emerge, either as a complication of traumatic injury or as a physical response to ongoing stress from violence or neglect. Health issues related to domestic violence include physical injury from the assault itself, such as bruises and broken bones (Choice B). Families experiencing domestic violence/ physical abuse have more unintended pregnancies, miscarriages, abortions, and low-birth-weight babies (Choice C). Families experiencing domestic violence have higher rates of substance abuse and depression (Choices E and F). Choice A is incorrect. While stress may affect immunity, upper respiratory infections are not particularly associated with physical abuse. Choice D is incorrect. Repetitive strain injuries are not particularly associated with physical abuse. They are seen with repetitive tasks performed over long periods, such as typing and using a computer mouse or assembling parts in a factory line. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Challenges Related to Family Health Last Updated - 14, Oct 2021

The nurse is caring for a client who has a factitious disorder. The client reports chest pain. Which of the following actions should the nurse take? Select all that apply. A. Provide reassurance that this is part of the disorder B. Notify the primary healthcare physician (PHCP) C. Obtain a 12-lead Electrocardiogram D. Disregard the symptom as it may be unreliable E. Assess vital signs Submit Answer

Explanation Choices B, C, and E are correct. Chest pain is a worrisome manifestation as it may be a clinical finding associated with myocardial infarction, pulmonary embolism, or other pathology. Despite the client having factitious disorder, which is characterized by the client feigning their symptoms, the nurse should intervene by notifying the PHCP, obtaining a 12-lead Electrocardiogram, and assessing vital signs. This is the standard of care for any client reporting an acute change such as angina. Choices A and D are incorrect. Factitious disorder is characterized by the client feigning their symptoms. Despite this characterization, the nurse must consider the validity of the client report and act accordingly. Reassuring the client and disregarding the report would be inappropriate because the nurse must consider physical needs first. Additional Info Factitious disorder is characterized by an individual feigning their symptoms. The individual falsifies medical or psychiatric symptoms. This disorder may be imposed on themselves or others (by proxy). Nursing care for a client with this disorder includes - Develop a therapeutic rapport with the patient. Avoid confrontation or power struggles. Focus on the patient's disorder - not symptoms. Investigate any new physical symptoms appropriately without them dominating the conversation. Last Updated - 09, Feb 2022

A nurse is caring for a child who has autism. Which of the following actions should the nurse take? Select all that apply. A. Withhold prescribed vaccines B. Have a family member bring in the child's favorite toys C. Dim the lights in the room D. Seclude the child for any misconduct E. Maintain consistent caregivers Submit Answer

Explanation Choices B, C, and E are correct. Clients with autism do well with an established routine; thus, having familiar objects from home is effective nursing care. Further, a low-stimulation environment with dim lights and low noise is more conducive for a client with autism. Finally, consistent caregivers may decrease the anxiety associated with change. Choices A and D are incorrect. A conclusive etiology of autism has yet to be established, but vaccines are not a risk factor. Finally, seclusion may heighten a client's anxiety and the nurse should provide positive reinforcement for good behavior. Additional Info Autism may manifest with repetitive behaviors, sensitivity to touch or sound, and difficulty with social reciprocity. ➢ The parents usually notice symptoms by three years of age. This may include odd mannerisms and difficulty with speech. ➢ Autism is best managed with an environment low in stimulation that is predictable for the client. ➢ The nurse should coordinate bedtime rituals and other routines with the parents. ➢ The nurse should reward good behavior through positive reinforcement. ➢ Early speech therapy and psychotherapy is essential. Last Updated - 11, Dec 2022

The nurse discusses the signs and symptoms of child abuse at an interprofessional conference. It would be correct for the nurse to identify which manifestations are associated with physical abuse? Select all that apply A. Verbal assault B. Sexual contact between legal parent/guardian C. Spiral fractures without any sports injury D. Scalded burns on legs E. Bruises without plausible explanation Submit Answer

Explanation Choices C, D, and E are correct. These manifestations are consistent with physical abuse. Physical abuse is when an individual deliberately causes a child pain and/or injury. The degree of physical abuse can be minor to severe. Scalded burn injuries, bruising without a plausible explanation, and spiral fractures without sports injuries are consistent with physical abuse. Choices A and B are incorrect. Verbal assault towards a child is verbal abuse. Sexual contact between legal parents/guardians is categorized as sexual abuse. Additional Info Risk factors for child abuse include - ➢ Children younger than four years of age ➢ Children with special needs that may increase caregiver burden (e.g., disabilities, mental health issues, and chronic physical illnesses) Caregivers who perpetuate abuse have risk factors such as - ➢ Substance use ➢ Caregivers who were abused themselves ➢ High levels of socioeconomic stress Source: CDC (2022) https://www.cdc.gov/violenceprevention/childabuseandneglect/riskprotectivefactors.html Last Updated - 28, Nov 2022

Which type of care environment is the most therapeutic and the most conducive for the treatment of clients with emotional and behavioral issues? A. A milieu environment B. A locked environment C. One employing mindfulness therapy D. One employing universal seclusion Submit Answer

Explanation Choice A is correct. A milieu environment is the type of care environment that is the most therapeutic and the most conducive for the treatment of clients with emotional and behavioral issues. A milieu environment is planned and maintained in a manner that eliminates all possible stressors so that the clients with emotional and behavioral problems can concentrate their energies and thoughts on the things impacting them rather than external stressors that have been eliminated from the environment of care. Choice B is incorrect. A locked environment is not the type of care environment that is the most therapeutic and the most conducive for the treatment of clients with emotional and behavioral issues. Clients are placed in a locked environment only when all alternative measures are not possible or practical, and the client is in grave danger to themselves and others, as consistent with the regulations of the Centers for Medicare and Medicaid Services and the Joint Commission on the Accreditation of Healthcare Organizations. Choice C is incorrect. Although mindfulness therapy is used for a large number of clients with different psychiatric mental health disorders in a wide variety of care environments, mindfulness is not the environment that is the most therapeutic and the most conducive for the treatment of clients with emotional and behavioral issues. Choice D is incorrect. An environment that employs universal seclusion for all clients is not the type of care environment that is the most therapeutic and the most conducive for the treatment of clients with emotional and behavioral issues. Seclusion and restraint are a last resort and, as such, they are not employed unless all other measures to protect the client and others from imminent harm have not been effective, as consistent with the regulations of the Centers for Medicare and Medicaid Services and the Joint Commission on the Accreditation of Healthcare Organizations. Last Updated - 05, Jun 2021

The nurse educator is talking to a group of students regarding anorexia nervosa. Which statement by the students indicates an understanding of the condition? A. "Clients with anorexia nervosa are usually perfectionists and overachievers." B. "Clients with anorexia nervosa display a binge-purge syndrome." C. "Clients with anorexia nervosa have poor dental conditions." D. "Clients with anorexia nervosa have stomach ulcers and rectal bleeding." Submit Answer

Explanation Choice A is correct. Clients with anorexia nervosa have the desire to please others. They need to be accurate or perfect to cope with their stress. Choices B, C, and D are incorrect. These statements apply to clients with bulimia nervosa, not anorexia. Additional Info Last Updated - 13, Oct 2021

A client in the psychiatric unit is having fits of uncontrolled anger. He is also seen shouting at staff and threatening to hurt them. The psychiatric nurse's most appropriate action would be: A. Call security to restrain and then sedate the client. B. Tell the client to calm down. C. Threaten the client to remove his privileges if he does not stop. D. Observe the client and leave him alone to calm down. Submit Answer

Explanation Choice A is correct. Once the client is at risk of harming himself, other clients, or staff, the nurse should call for help and prepare to administer a sedative/tranquilizer to calm him down. De-escalation should be continued all the time, talking, reassuring, and negotiating. However, physical intervention should be undertaken quickly in this mentally unstable patient. Physical restraint should be the minimum necessary for the shortest period. Control is best done seated on a bed or kneeling, then restrain supine, not prone. Physical restraint should be accompanied by rapid sedation with medications. Choice B is incorrect. The client is enraged and agitated. Telling the client to calm down will not deescalate the crisis and may provoke the client even more. If the client is otherwise mentally stable, acknowledging his distress without making accusations may help. For example, comments such as 'you are upset' or 'you seem very angry' may help calm the patient if he is not mentally unstable. In the case of mentally stable patients, one could also use disarming comments such as 'how can I help?'. Asking the patient how to defuse the situation may also help, referred to as 'positive engagement' in mental health practice. In this patient scenario, he is mentally unstable, and there is a risk of an impending threat to the staff involved. Choice C is incorrect. Threatening the client may also provoke him and escalate the crisis. Threats or getting angry yourself never helps. A nurse must respond to anger or conflict in a calm and measured way, promoting collaboration and avoiding further provocation. Such an approach is referred to as 'emotional and behavioral self-regulation.' Choice D is incorrect. If a violent incident is imminent, you need to intervene. The criterion to act is a severe immediate risk of harm to the patient, other patients, visitors, or staff. Leaving the client alone may lead to the client or others getting injured. Learning Objective Understand that a mentally unstable client at risk of injuring himself or others must be restrained and sedated. Restraint should be for the shortest duration possible. The sedative must be rapid-acting and short-acting. Additional Info In mentally unstable patients at risk of harming themselves or others, physical restraints should be accompanied by rapid sedation with medications. Quick control is required within 30-60 minutes. The sedative should have an early onset of action but not enough to cause harm. The exhibit below shows some preferred sedatives in this setting because of the "rapid onset" and "short duration" of action. Healthcare providers usually order lorazepam - often the first-line drug in mental health settings, due to concerns that haloperidol can be arrhythmogenic. A few essential nursing considerations after administering rapid acting sedatives include: The nurse should monitor vital signs continuously if necessary. The nurse should wait about 20 to 30 minutes before re-administering a dose since these drugs take about 20 to 30 minutes to produce a peak effect. The nurse should monitor for the desired effect and understand the side effects. The nurse should keep flumazenil ready in case respiratory depression occurs with benzodiazepines. The nurse should keep anticholinergics like diphenhydramine or benztropine available as an antidote if side effects like dystonic reactions occur from haloperidol. Last Updated - 11, Nov 2021

After experiencing a traumatic amputation and related body image disturbance. The nurse documents the nursing diagnosis of body image disturbance related to changes in appearance secondary to: A. Severe trauma B. Loss of a body part C. Chronic disease D. Loss of body function Submit Answer

Explanation Choice B is correct. Although the amputation was related to severe trauma, being specific about what type of injury (the loss of a body part) gives precise information to other health care team members who may assume care of this client. The nursing diagnosis is body image disturbance. When referencing a nursing diagnosis that is secondary to a condition/experience, it is essential to be specific. Choice A is incorrect. The loss of a limb was caused by severe trauma but is not the most appropriate answer to this question. Choice C is incorrect. Amputation is a chronic condition but is not a disease. Choice D is incorrect. While the loss of body function will become evident, it is about the loss of the limb, which is the most appropriate answer. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Body Image Last Updated - 21, Dec 2021

A patient who has recently been brought to the emergency department after experiencing a very traumatic event appears calm and in total control. The nurse assesses this behavior as which of the following defense mechanisms? A. Projection B. Denial C. Rationalization D. Regression Submit Answer

Explanation Choice B is correct. Denial is a coping mechanism used to protect a patient from a traumatic experience. A patient in denial will behave as though the trauma never occurred. Choice A is incorrect. Projection is a defense mechanism where the patient takes their personal feelings and places them onto someone else, believing the other person is experiencing the undesired feelings. Choice C is incorrect. Rationalization involves working to find a good reason for something negative occurring. Choice D is incorrect. Regression is a coping mechanism where a patient behaves in a manner reminiscent of an earlier, safe time in their life. NCSBN client need Topic: Psychosocial integrity, coping mechanisms Additional Info Last Updated - 07, Feb 2022

At an eating disorder treatment center, a nurse is caring for a client with anorexia nervosa who has recently arrived at the facility. Which intervention should the nurse apply following the client's meals? A. Instruct the client to exercise by going for a walk following meals B. Restrict the client from using the restroom for 90 minutes after each meal C. Ask the client to lie down for two hours after each meal D. Encourage the client to begin an intense exercise program, with short exercise sessions after each meal Submit Answer

Explanation Choice B is correct. The nurse should observe the client while eating and prevent the client from using the restroom for 90 minutes each meal to break the purging cycle. Although purging is traditionally associated with bulimia, purging is actually seen in both in both anorexia and bulimia (while this sounds very similar to bulimia, the primary difference is that in bulimia, clients are of normal or above-normal weight, whereas those with anorexia nervosa (even the binge eating/purging type) have a significantly low body weight). Binge eating with purging occurs in 30 to 50% of anorexia clients; therefore, the post-meal restroom restriction is needed to ensure anorexia clients are not purging. Choice A is incorrect. Beyond a very low intensity exercise (i.e., walking at a slow pace, stretching) for a short period of time, exercise should not be encouraged until the client has shown adequate weight gain and met the eating disorder treatment program's requirements before allowing the client to engage in exercise. Choice C is incorrect. There is no specific indication for the client to lie down after meals. Choice D is incorrect. Encouraging an intense exercise program would be detrimental to the client and is therefore contraindicated. The maximum amount of exercise the client should be allowed to participate in would be a very low intensity workout (i.e., walking at a slow pace, stretching, etc.) for a short duration of time. Exercise should not be encouraged until the client has shown adequate weight gain and met the eating disorder treatment program's requirements before allowing the client to engage in exercise. Learning Objective When caring for a client with anorexia nervosa, recognize the need to restrict the client from using the restroom for 90 minutes following each meal. Additional Info Anorexia nervosa occurs predominantly in girls and young women. The onset of this disease usually occurs during adolescence and rarely occurs after age forty. Two types of anorexia nervosa are recognized: In the restricting type of anorexia nervosa, clients restrict food intake but do not regularly engage in binge eating or purging behavior. Additionally, some of these clients exercise excessively. In those with the binge eating/purging type of anorexia nervosa, clients regularly binge eat before inducing vomiting and/or misusing laxatives, diuretics, or enemas. Unlike bulimia clients (who are of normal or above-normal weight), these clients have a significantly low body weight. Clients with anorexia nervosa have an intense fear of gaining weight or becoming fat that persists despite all evidence to the contrary. In adults, BMI is significantly low (usually BMI of < 17 kg/m2), and in adolescents, BMI percentile is low (usually < 5th percentile) or does not increase as expected for normal growth. Endocrine or electrolyte abnormalities or cardiac arrhythmias may develop, potentially resulting in death. Treatment consists of nutritional supplementation and psychotherapy (e.g., cognitive behavioral therapy). For adolescents, family-based therapy is often utilized. Last Updated - 26, Oct 2022

A nurse educator is shadowing a student nurse caring for a psychiatric client. The nurse educator should instruct the student that a therapeutic nurse-client relationship starts with: A. A sincere desire to help others B. Acceptance C. Understanding and self-awareness D. Knowledge of psychiatric nursing Submit Answer

Explanation Choice C is correct. The foundation for a robust nurse-client relationship must begin with the student's thorough understanding and self-awareness of their own beliefs, biases, feelings, values, etc. Choice A is incorrect. Although a desire to help others is a desirable trait in an individual seeking to create a therapeutic nurse-client relationship, these types of relationships are not formed on one's desire to help others alone. Choice B is incorrect. Although acceptance is a desirable trait in an individual seeking to create a therapeutic nurse-client relationship, these types of relationships are not formed solely on one's ability to accept others. Choice D is incorrect. Although knowledge of psychiatric nursing is a desirable trait for individuals seeking to create a therapeutic nurse-client relationship, these types of relationships cannot be formed solely because the student possesses knowledge of psychiatric nursing. Regardless of the amount of knowledge of psychiatric nursing possessed, one must have a thorough understanding and self-awareness of their own beliefs, biases, feelings, values, etc., in order to form the proper foundation for a nurse-client relationship. Learning Objective Recognize that a therapeutic nurse-client relationship starts with understanding and self-awareness. Additional Info One must maintain self-awareness to prevent unrecognized beliefs, biases, feelings, values, etc. from affecting client care. Although acceptance is a vital aspect of the nurse-client relationship, acceptance of others requires understanding and acceptance of self first. Self-awareness must be continually maintained, as our beliefs, biases, feelings, values, etc., fluctuate over time. Last Updated - 16, Jan 2023

Your client was admitted to your medical telemetry unit for acute renal failure. The client is demonstrating mild restlessness while asking numerous questions regarding their diagnosis and treatment. This client is most likely experiencing: A. Hypokalemia B. Hyperkalemia C. Mild to moderate anxiety D. Panic attack Submit Answer

Explanation Choice C is correct. When experiencing mild anxiety, physical symptoms such as restlessness and irritability may be present while the client's problem-solving ability becomes more effective, typically by grasping for information. The client is exhibiting mild restlessness while inquiring about the new diagnosis of acute renal failure and the various treatment options that correlate with effective problem-solving. These objective findings align with mild anxiety symptoms; therefore, one may appropriately reason this client is most likely experiencing mild anxiety. Moreover, mild anxiety would be a foreseeable response if this was a new diagnosis for this client. Choice A is incorrect. Hypokalemia occurs when the serum potassium level falls below 3.5 mEq/L (3.5 mmol/L). Any potassium level lower than 3 mEq/L (3 mmol/L) is considered severe hypokalemia. Although those with mild hypokalemia are often asymptomatic, those with severe hypokalemia may exhibit palpitations, fatigue, hypotension, arrhythmias, muscle weakness, and/or muscle cramping. Although some of these clinical symptoms may be present in the question, the symptoms indicated within this scenario are more indicative of a psychosocial issue and not suggestive of hypokalemia. Choice B is incorrect. Hyperkalemia occurs when the serum potassium rises above 5.0 mEq/L (5.0 mmol/L). Typically, hyperkalemia occurs due to an increased potassium intake or an ineffective ability of the kidneys to excrete potassium effectively. When hyperkalemia develops slowly, symptoms are typically subtle. When the onset of hyperkalemia emerges rapidly, symptoms may include palpitations, angina, shortness of breath, nausea, and/or vomiting. The symptoms described in the question's scenario do not align with those typically present in a hyperkalemia client insomuch as an individual with a psychosocial concern. Although severe restlessness may likely be a neuromusculoskeletal symptom of hyperkalemia, that restlessness is typically accompanied by significant irritability, paresthesia, and weakness to the point of ascending flaccid paralysis. Here, the client is experiencing mild restlessness only and lacks any of the accompanying symptoms. Choice D is incorrect. A panic attack is the key feature of panic disorders. When a panic attack occurs, the onset is typically sudden and consists of extreme apprehension, fear, or impending doom. These events do not necessarily occur in response to a specific stressor. Physical symptoms of a panic attack may include chest pain, palpitations, hyperventilation, chills, nausea, etc. Here, the client is not experiencing such symptoms, as this client is capable of remaining calm and collected enough to engage in a productive dialogue regarding the diagnosis of acute renal failure while inquiring about treatment options. Learning Objective Utilize the objective information provided to determine what the client in question is currently experiencing. Additional Info · When a client experiences hyperkalemia or hypokalemia (regardless of the underlying causation), the client is at an increased risk for cardiac arrhythmias. Therefore, when admitted, the client should be placed on an appropriate floor and wear a cardiac monitor throughout their admission. · A client experiencing mild to moderate anxiety remains capable of solving problems. · It is important to note that the client's ability to concentrate decreases as anxiety increases. If a nurse anticipates a client trending in that direction, the nurse should assist the client in focusing and solving problems through specific active listening communication techniques. · While individuals respond differently to receiving a new medical diagnosis, mild to moderate anxiety and questions regarding the diagnosis and treatment are not uncommon when an individual receives a new diagnosis.

Select the age group that is accurately paired with an expected outcome that would indicate effective coping with their age-related stressor. A. Infants: will develop autonomy. B. Toddlers: will compete in the school environment. C. Adolescents: will begin to manage their home. D. Middle-aged adults: will cope with the challenges of the "sandwich generation". Submit Answer

Explanation Choice D is correct. During the middle-aged adult years, there is a lot of coping with challenges associated with work, raising adolescent children, and caring for their adult aging parents. Caring for one's children and caring for aging parents places middle-aged adults in the "sandwich generation". Choice A is incorrect. Infants have to cope with and develop trust, but not autonomy. Choice B is incorrect. Toddlers have to cope with and develop autonomy, but not compete in the school environment. Choice C is incorrect. Adolescents have to cope with the changes associated with puberty and the development of interpersonal relationships, but not managing the home. Last Updated - 10, Feb 2022

The nurse is planning a staff development conference about hospice services. Which of the following information should the nurse include? A. Hospice services are useful for symptom management of acute diseases. B. Treatment is limited to pain management and symptom control. C. The goal is to implement curative therapies and treatments. D. Services may be offered in settings such as the home and inpatient. Submit Answer

Explanation Choice D is correct. Hospice is a service that provides comfort and dignity for clients with six or fewer months left to live. This service is flexible in that it may be rendered, inpatient and outpatient. Hospice services may be provided to individuals incarcerated or in long-term care. It also can be provided in specialized facilities. The portability of this service is one of its many benefits. Choices A, B, and C are incorrect. Hospice services are not utilized for acute diseases. A key difference between hospice and palliative care is that hospice is prescribed for individuals with a prognosis of six months or less with a terminal illness. The goal of these services is not curative; rather, it provides care that eases suffering and promotes maximum comfort. Services are broad and may include respite care for caregivers, pain management, specialized medical devices, medication management, and physical therapy. Additional Info Hospice service differs from palliative care in that hospice is prescribed for those with an illness with a prognosis of six months or less. Palliative care may be ongoing, and the goal of this type of care is symptom management for chronic illnesses. Common illnesses that receive palliative care include congestive heart failure and dementia. Once these illnesses have become end-stage, a hospice referral may be considered depending on the prognosis (if it is six months or less). Last Updated - 18, Dec 2022

While working in the emergency department, the nurse is taking care of a client who has overdosed on morphine. Which of the following medications does she expect the healthcare provider will order? A. Sodium bicarbonate B. Flumazenil C. Diphenhydramine D. Naloxone Submit Answer

Explanation Choice D is correct. Naloxone is the antidote for opioid overdose. Naloxone would be used in the overdose of morphine, fentanyl, oxycodone, or other opioid medications. Choice A is incorrect. Sodium bicarbonate is a base produced by the kidneys to buffer the pH of the blood. When the pH is acidic, sodium bicarbonate is produced to help bring the pH back to the appropriate range. This medication is administered when there is an acid-base imbalance in the body, specifically for an acidotic pH with a base deficit. It would not be indicated in the care of a morphine overdose. Choice B is incorrect. Flumazenil is the antidote for benzodiazepine overdose. Morphine is an opioid, not a benzodiazepine, so the nurse would not expect to administer flumazenil to this patient. Choice C is incorrect. Diphenhydramine is an antihistamine commonly prescribed for allergies. There would be no indication for diphenhydramine in a morphine overdose, so the nurse would not expect to administer this to the patient. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies; Fundamentals - Medication Administration

The nurse in the psychiatric unit notes that a client with paranoid schizophrenia is yelling and blocking the television. Other psychiatric clients around the yelling client are now becoming agitated. What is the most appropriate action for the nurse? A. Restrain the client B. Escort the other clients from the room C. Administer haloperidol via intramuscular (IM) injection to the client causing a disruption D. Approach the client causing a disruption calmly while accompanied by two additional staff members Submit Answer

Explanation Choice D is correct. The initial intervention is to approach the client calmly, attempt to de-escalate the situation, and remove this client from the room (preferably on the client's own accord). For the safety of staff and all other individuals in the room, staff members should never make face-to-face contact with an agitated psychiatric client without being accompanied by other trained healthcare personnel. Choice A is incorrect. The use of physical restraints for this client (or any client) is typically reserved as a final approach. The first nursing intervention should be an attempt by the nurse to verbally de-escalate the situation with the goal of ultimately removing the client from the room peacefully. Choice B is incorrect. Unless the situation escalates to the point where the other clients are placed in physical danger, the nurse should try to avoid removing the other clients from the room, as these clients are not the individuals causing the issue at hand. The primary goal for the nurse in this situation should be to remove the disruptive client from the room. Choice C is incorrect. Although an intramuscular (IM) injection of haloperidol may be indicated at some point, this is not the most appropriate action for the nurse at this time. First, even if the client has an existing PRN order for this medication, accessing and preparing the medication will take time. Second, the client is currently agitated. Attempting to physically restrain the client to provide the client with an IM haloperidol injection will not only increase the client's agitation, but significantly jeopardize the nurse and other staff members' safety. Third, an IM injection of haloperidol does not work instantaneously, as the medication's onset of action is approximately 15 minutes. Therefore, before resorting to an IM injection of haloperidol, the nurse should exhaust all other less invasive options. Learning Objective When caring for a client with paranoid schizophrenia who is yelling and blocking the television in a room full of other psychiatric clients, identify that the most appropriate nursing action is to approach the disruptive client calmly while accompanied by two additional staff members. Additional Info Aggressive and disruptive behavior in inpatient settings poses a serious challenge for nurses, clinical staff, and fellow clients. Studies have found that clients with major depressive disorder exhibit significantly higher externally directed aggression, reactive aggression, and irritability than controls. Studies have also shown clients with schizophrenia tend to display higher irritability with distinctly higher self-aggressiveness than healthy persons. Last Updated - 21, Dec 2022

You are assessing a 16-year-old female with anorexia nervosa. Which of the following symptoms and signs would you expect to find? Select all that apply. A. Lanugo B. Heavy menstrual periods C. Hypertension D. Hypothermia Submit Answer

Explanation Choices A and D are correct. Lanugo (Choice A) is defined as "fine and soft hair that covers the body and limbs of a human fetus/newborn." It is abnormal for a 16-year-old to have lanugo. In a patient who is severely underweight and has lost a large amount of subcutaneous fat, such as in a patient with anorexia nervosa, the body will develop lanugo as a way to insulate itself. Hypothermia (Choice D) is a severe complication of anorexia nervosa. Subcutaneous fat is necessary to insulate the body and regulate the temperature. Clients with anorexia nervosa lose a significant amount of subcutaneous fat due to malnourishment and weight loss. Consequently, they are prone to hypothermia. Choice B is incorrect. Amenorrhea (lack of menstrual period) rather than increased menses is a complication seen in anorexia nervosa—self-inflicted starvation in anorexia nervosa results in malnourishment, hormonal imbalance, and amenorrhea. Choice C is incorrect. Hypotension is seen in anorexia nervosa, not hypertension. Clients with anorexia are prone to malnourishment and dehydration. Dehydration results in fluid-volume deficit and hypotension. Electrolyte imbalance such as hypernatremia is also seen due to free water deficit and concentrated body fluids. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Mental health Additional Info Last Updated - 27, Nov 2021

The nurse is instructing a client who is scheduled for electroconvulsive therapy (ECT). Which of the following statements by the client would require follow-up? Select all that apply. A. "I can take my morning antidepressant with a sip of water." B. "I may feel a flushing sensation as the contrast dye is given." C. "I should be able to drive home after this procedure." D. "I will need one treatment for my depression to go into remission." E. "I may experience some confusion after this procedure." Submit Answer

Explanation Choices B, C, and D are correct. ECT is a safe therapy that induces seizures theorized to release monoamines, which may assist in treating psychiatric illnesses such as major depressive disorder and significant psychosis. Clients do not receive contrast dye ( Choice B) for this procedure; instead, this procedure involves no imaging and requires general anesthesia. Driving home after the procedure is prohibited because of the post-procedural confusion from general anesthesia and the ECT procedure itself ( Choice C). Clients may experience remission after several treatments, but one treatment is highly unlikely to bring remission ( Choice D). Instead, one session of ECT may bring some symptom improvement Choices A and E are incorrect. Antidepressants and antipsychotics may be given concurrently with ECT and may be taken with a sip of water on the day of the procedure ( Choice A). ECT works by producing a minor seizure. Any medications that interfere with ECT seizures such as anticonvulsants and benzo-diazepines ( BZDs) should not be given concurrently. However; antidepressants do not interfere with the ECT mechanism and should be given because holding antidepressants may cause a flare of depression if ECT did not work as expected. Holding anti-depressants may also precipitate withdrawal symptoms. Updated evidence-based information recommends concurrent use of antidepressants with ECT. Post-procedural confusion is the most common unwanted effect of this procedure as it is linked to the general anesthesia used and the procedure itself ( Choice E). NCSBN Client need: Topic: Reduction of Risk Potential; Subtopic: Therapeutic Procedures Learning Objective Understand that electroconvulsive therapy ( ECT) is performed under general anesthesia and used to treat major depression and psychosis. Additional Info A stigma is attached to ECT that it is somehow inhumane. This stigma is false as ECT is highly effective when medications are ineffective. ECT is a safe treatment for various conditions, including major depressive disorder, psychosis, and post-partum disorders. Common side effects associated with ECT include headache and cognitive impairment that may be temporary. Last Updated - 03, Feb 2022

The nurse is attending to a client who was just diagnosed with terminal cancer. He continues to claim the "cancer is just going to disappear on its own." Knowing that this is an acceptable response by the client, please arrange the following stages of the Kübler-Ross model of grieving in the correct ordered sequence: Denial Anger Bargaining Depression Acceptance Submit Answer

Explanation The correct ordered sequence is Denial, Anger, Bargaining, Depression, and Acceptance ("DABDA"). Denial: Refuses to believe that loss is happening. The client is unready to deal with practical problems, i.e. prosthesis after the loss of a leg. May assume artificial cheerfulness to prolong denial. This client is currently in denial. Anger: The client or family may direct anger at nurses or staff about matters that generally would not bother them. Bargaining: Seeks to bargain to avoid loss (e.g. "let me just live until ___ and then I will be ready to die"). Depression: Grieves over what has happened and what cannot be. May talk freely (e.g. reviewing past losses such as money or a job), or may withdraw. Acceptance: Comes to terms with the loss. May have decreased interest in surroundings and support people. May wish to begin making plans (e.g. will, prosthesis, altered living arrangements). NCSBN Client Need Topic: Psychosocial Integrity; Mental health concepts, Subtopic: Loss & Grief Last Updated - 16, Jan 2020

The nurse has established a support group for individuals with major depressive disorder (MDD). The nurse recognizes that this support group is A. tertiary prevention. B. primary prevention. C. secondary prevention. D. essential prevention. Submit Answer

Explanation Choice A is correct. Establishing a support group for individuals with a disease or disorder to maximize their functioning is tertiary prevention. Choices B, C, and D are incorrect. The crux of secondary prevention is to screen and detect diseases and disorders. Primary prevention is true prevention that involves vaccination and education. Additional Info Primary prevention is true prevention. Its goal is to reduce the incidence of disease. Primary prevention includes health education programs, nutritional programs, and physical fitness activities. It includes all health promotion efforts and wellness education activities that focus on maintaining or improving the general health of individuals, families, and communities Secondary prevention focuses on preventing the spread of disease, illness, or infection once it occurs. Activities are directed at diagnosis and prompt intervention, thereby reducing its severity. Examples include identifying people who have a new case of a disease or following people who have been exposed to a disease but do not have it yet. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration. Activities are directed at rehabilitation rather than diagnosis and treatment. Last Updated - 06, May 2022

What is the greatest priority of care for a client with the nursing diagnosis "at risk for self-directed violence"? A. The preservation of life B. The assessment of the client C. Encouraging the expression of the client's feelings D. Determining the client's social support systems Submit Answer

Explanation Choice A is correct. The highest priority of care for a client with the nursing diagnosis of "at risk for self-directed violence" is the preservation of life, as consistent with Maslow's hierarchy of needs. Choice B is incorrect. Based on the assessment of this client, you have arrived at this diagnosis, and, although ongoing assessments are necessary, the preservation of life is the highest priority of all. Choice C is incorrect. Although suicidal clients should also be encouraged to express their feelings in an open and non-judgmental manner, this is not the highest priority of all. Choice D is incorrect. Although the nurse should determine and assess the client's social support systems, this is not the highest priority of all. Last Updated - 23, Jan 2022

The school nurse is assessing a 12-year old boy who came into her office for a nose bleed. She notices several bruises on his back and forearms that are in various stages of healing. When she asks the boy about them, he is very deceptive. The nurse notifies child protective services of her suspicion. The next day, the boy's mother comes to the nurse's office and yells at her for calling child protective services. Which of the following responses is most appropriate? A. "I am required by law to report any suspected violence." B. "You should have thought about this before you abused your son." C. "I'm so sorry. Please don't take this out on me." D. "Don't talk to me about this. I don't want to see you." Submit Answer

Explanation Choice A is correct. The nurse is a mandatory reporter of any suspected violence and is required by law to report her suspicions. Parents may become upset and confront the nurse when these allegations come to light, but that should not stop the nurse from saying what she has seen. The nurse should remain calm when the parent confronts her and she should state that she is required to report any suspected violence. Choice B is incorrect. This statement is an accusation and could further aggravate the mother. The nurse does not know that she abused her son and should not make statements such as this one. The nurse needs to remain calm and stick to the fact that she is required to report any suspected violence. Choice C is incorrect. This statement is based on emotion, not fact. The nurse should not apologize to the mother. Instead, she should remain calm and inform her that she is required to report any suspected violence. Choice D is incorrect. This is not an appropriate statement. By telling the mother, she doesn't want to see her; she could further aggravate the mother and place herself in a dangerous situation. The nurse needs to remain calm and stick to the facts. If she feels like she is not safe with the mother, she should move to an open area where others are nearby. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Pediatrics - Abuse & Neglect Last Updated - 19, Jan 2021

Which nursing diagnosis is most appropriate for a caregiver abusing drugs and alcohol to self-medicate to overcome caregiver stress? A. Ineffective coping related to alcohol and abuse B. Ineffective coping related to responsibilities required in the caregiver's role C. The client will make better lifestyle choices D. The client will attend two 12-step recovery programs per week for one month Submit Answer

Explanation Choice B is correct. "Ineffective coping related to responsibilities required in the caregiver's role" is an appropriate nursing diagnosis for a caregiver who abuses alcohol and drugs to self-medicate to overcome caregiver stress. Choice A is incorrect. "Ineffective coping related to alcohol and abuse" is not an appropriate nursing diagnosis for a caregiver abusing drugs and alcohol. The use of drugs and alcohol signifies the individual is in a self-sabotage or destructive coping stage, both of which are signs and symptoms of ineffective coping. Choice C is incorrect. "The client will make better lifestyle choices" is not an example of a nursing diagnosis. Although this option appears to be an expected outcome, it is important to remember that an expected client outcome must be measurable. Here, "[t]he client will make better lifestyle choices" is not a nursing diagnosis nor an expected client outcome. Choice D is incorrect. "The client will attend two 12-step recovery programs per week for one month" is an example of an appropriate client outcome, not a nursing diagnosis. Learning Objective Utilize the objective information provided to determine the most appropriate nursing diagnosis for the client in question. Additional Info Ineffective coping is the inability to make sound decisions due to the failure to assess a stressful life event. The individual may have difficulty asking for assistance, locating the appropriate resources, or utilizing the appropriate problem-solving skills to manage the situation. An individual who is ineffectively coping may have difficulty meeting their own basic needs, such as food and shelter (i.e., the lower level of Maslow's Hierarchy of Needs), let alone the role of caregiver. An expected outcome is a measurable behavior demonstrated by the client responsive to nursing interventions. Source : Archer Review Last Updated - 28, Jul 2022

The nurse is triaging a child with bilateral lower extremity chemical burns. The nurse suspects that the child may have been abused. The nurse should take which initial action? A. Cover the affected area with sterile dressing B. Irrigate the affected area with saline C. Report the suspected abuse D. Document the findings Submit Answer

Explanation Choice B is correct. A common mnemonic to remember is "the solution to pollution is dilution." When a client has a chemical burn, the highest priority is to copiously irrigate it (dilute it) with saline or water. Prompt irrigation of the area exposed to caustic substances ( acid, alkali) dilutes the chemical, attempts to neutralize the pH change in the skin, and decreases the extent of the dermal injury. Additionally, dilution lessens the risk of the caregiver getting burned by the chemical. Choices A, C, and D are incorrect. All of these actions are appropriate, but the nurse should not prioritize these actions over caring for the client's immediate physical needs ( applying Maslow's hierarchy while answering priority questions, one should address the physical needs first). Before suspected abuse should be reported ( Choice C), the nurse should stabilize the client. Irrigation to decrease further damage to the client's integument is the highest priority with any chemical burn. Learning Objective Prioritize immediate irrigation to lessen the risk of further damage to the client with a chemical injury. Additional Info In the case of chemical injuries, decontamination is the focus of urgent treatment. Contaminated clothing is removed, and chemicals in powder form are brushed off. Then the burn is irrigated with copious amounts of water. Last Updated - 26, Jul 2022

A nurse is assigned to care for several clients with eating disorders. Based on physical appearance, how would the nurse differentiate between clients affected with bulimia nervosa from clients with anorexia nervosa? A. Observing the clients' teeth B. Differences in the clients' body mass index C. Mallory-Weiss tears D. It is impossible to distinguish these clients based only on a physical exam. Submit Answer

Explanation Choice B is correct. Clients with anorexia nervosa often present with a body mass index (BMI) of < 17 (i.e., underweight). This is due to the severe caloric restriction anorexia nervosa clients implement on themselves. Conversely, the body weight of clients with bulimia nervosa tends to fluctuate around normal, periodically going above this range (i.e., the majority of bulimia nervosa clients have a BMI ranging between 18.5 and 30). This higher BMI is due to the binging and purging of high-calorie foods by clients with bulimia nervosa. Choice A is incorrect. Not all bulimic clients have enamel loss on their teeth, especially if the disorder has developed only recently. Mallory-Weiss tears are small tears in the esophageal mucosa brought about by forceful vomiting but aren't always present in bulimic clients. Choice C is incorrect. A laceration of the lower esophagus or the upper portion of the stomach during forceful vomiting or retching (i.e., including bulimia nervosa-associated purging) is called a Mallory-Weiss tear. The diagnosis of a Mallory-Weiss tear occurs based on clinical symptoms, typically including a clinical history of hematemesis occurring after one or more episodes of non-bloody vomiting. Clients with anorexia nervosa with not have these clinical symptoms or a history of Mallory-Weiss tears. Choice D is incorrect. Based solely on a physical examination, clients with anorexia nervosa are distinguished from those with bulimia nervosa due to body mass index (BMI) differences as discussed in Choice A. Learning Objective Identify differences in body mass indexes (BMIs) as the most efficient way to distinguish clients affected with bulimic nervosa from those with anorexia nervosa. Additional Info In clients with anorexia nervosa, the body mass index calculation often falls within the "underweight" range. Unlike clients with anorexia nervosa, clients with bulimic nervosa rarely lose much weight or develop nutritional deficiencies. Last Updated - 10, Nov 2022

The nurse is assessing a client experiencing psychosis. The client states, "I am convinced my wife and brother-in-law want to kill me." The nurse interprets this statement as a A. delusion of reference. B. delusion of persecution. C. delusion of grandeur. D. delusion of erotomania. Submit Answer

Explanation Choice B is correct. Delusion of persecution is when an individual is falsely convinced someone is out to get them or intends to cause them harm. This is a serious delusion because the client may react with violence. Choices A, C, and D are incorrect. A delusion of reference is when an individual is convinced that something they are observing is explicitly meant for them. For example, a client is watching a television newscast about a wanted individual and is convinced that the individual is them. Delusion of erotomania occurs when an individual is convinced that someone is in love with them. Delusion of grandeur is when an individual has a self-inflated view of themselves. Additional Info Key interventions for a client experiencing a delusion include - Build trust by being open, honest, genuine, and reliable. Respond to suspicion in a matter-of-fact, empathic, supportive, and calm manner. Ask the client to describe their beliefs. Do not use avoidance. Inquire about the delusion and its content. Never debate the delusional content. Validate if part of the delusion is real. Example - "Yes, there was a package at the nurses' station, but it did not contain a recording device." Last Updated - 25, Jul 2022

The nurse is assessing a client with post-traumatic stress disorder (PTSD). Which assessment finding would be expected? A. Delusions of grandeur B. Hypervigilance C. Circumstantial speech D. Flight of ideas Submit Answer

Explanation Choice B is correct. PTSD is characterized by an individual who has experienced (or witnessed) a traumatic event such as sexual assault, combat, violence, or medical illness. The client then experiences significant cognitive, affective, and behavioral responses to stimuli reminding them of the trauma they experienced. This chronic psychiatric condition causes a client to experience manifestations such as night terrors, avoidance of anything that may trigger trauma memories, being easily startled, decreased concentration, hypervigilant, and sleep disturbances. This may cause the client to feel 'always on edge.' Dissociative symptoms may occur with PTSD, such as derealization or depersonalization. Choices A, C, and D are incorrect. Delusions of grandeur (false self-inflated view of themselves), circumstantial speech (speech pattern that takes a long time to get to the point), and flight of ideas (flood of unrelated ideas) are all manifestations associated with mania that may be found in bipolar disorder. These are not features of PTSD as the client may become more affectively constricted and socially retract. Additional Info ✓ PTSD is a condition that requires trauma leading to intrusive symptoms, avoidance of particular stimuli, alterations in mood, and hyperactivity. ✓ Clinical features include hyperarousal, social retraction, hypervigilance, night terrors, and potentially dissociative symptoms. ✓ This is a chronic disorder that responds favorably to psychotherapy. ✓ Other treatments include prazosin for night terrors and SSRIs (such as citalopram) for mood symptoms. ✓ Nursing care aims to build and maintain a therapeutic rapport with the client, encourage the verbal expression of feelings, and provide opportunities for therapeutic group therapy. Last Updated - 13, Feb 2023

Your client is expressing feelings of dread and impending danger. As you allow the client to freely express these feelings, you attempt to determine the cause of these feelings but are unable to identify the source. What is the most likely nursing diagnosis for this client? A. Fear related to an unidentifiable source B. Anxiety related to an unidentifiable source C. Ineffective coping related to a source that is not based on reality D. Maladaptive coping related to a source that is based on reality Submit Answer

Explanation Choice B is correct. The most likely nursing diagnosis for this client is "anxiety related to an unidentifiable source". Unlike fear, anxiety can result from an unidentifiable source as well as one that is identifiable. Fear is related to an identifiable source. Choice A is incorrect. Fear is related to an identifiable source and not an unidentifiable source. Choice C is incorrect. The nursing diagnosis of "ineffective coping related to a source that is not based on reality" is not accurate because this client's feelings may or may not be based on reality. Choice D is incorrect. The nursing diagnosis of "maladaptive coping related to a source that is based on reality" is not accurate because this client's feelings may or may not be based on reality. Last Updated - 26, Jan 2022

A woman comes into the emergency department complaining of insomnia, anxiety, difficulty breathing, and a sense of impending doom. After being assessed by the physician, no physiological abnormalities were found. However, the client is still anxious and apprehensive. What is the most appropriate statement from the nurse to the patient? A. "Don't worry, you're safe here. Just try to relax." [2%] B. "Can you think of anything that happened recently or in the past that might have triggered these feelings?" [75%] C. "We gave you something that should calm you down." [1%] D. "Take slow, deep breaths, and try to relax. Nothing bad will happen to you here."

Explanation Choice B is correct. This is an appropriate response from the nurse because it offers reassurance to the client while providing an opportunity for the nurse to gain insight into the client's anxiety. Choice A is incorrect. This statement disregards the client's feelings and offers false reassurance. This is an inappropriate response by the nurse. Choice C is incorrect. Telling the client that you gave her some medication disregards her feelings and does not allow her to discuss those feelings. This statement also offers some form of false reassurance to the client. Choice D is incorrect. This statement disregards the client's feelings and offers false reassurance. This is an inappropriate response by the nurse. Last Updated - 31, Dec 2021

Parents bring their 2-year old daughter into the emergency department after picking her up from her aunt's house. They are concerned that she has an upper respiratory infection. The nurse notices bruises on the patient's posterior thigh, wrists, and upper back. They appear to be in different stages of healing. Once the patient is stable after administering a bronchodilator and steroid, what should the nurse do? A. Question the parents B. Call the department of child and family services (DCFS) C. Call poison control D. Obtain an arterial blood gas (ABG) Submit Answer

Explanation Choice B is correct. This patient has bruises on her thigh, wrists, and upper back that are in different stages of healing, which is a reliable indicator of abuse. Bruising on these parts of the body is not a common area for 2-year olds to injure. Typical areas of injury are the knees elbows and chin. Thigh, wrist, and upper back injuries can be due to grabbing, burning, or pushing. The department of child and family services (DCFS) needs to be contacted by the nurse because nurses are mandated reporters. Recognizing signs of abuse is extremely important. Choice A is incorrect. The parents do not need to be questioned at this point. Once the nurse calls DCFS, they will handle the questioning and investigation. Assessing these bruises is enough assessment findings to call DCFS. Choice C is incorrect. There is no indication to call poison control at this time. Choice D is incorrect. If the patient's respiratory status were unstable, this would be necessary. However, the patient is stable at this time on a bronchodilator and steroids. NCSBN Client Need Topic: Safe and Effective Care Environment, Sub-topic: Care Management, Abuse Last Updated - 25, Jan 2022

The nurse is working with a woman who is five months pregnant and attending her first prenatal appointment after completing the client's history. The nurse suspects that she is a victim of domestic violence. Which of the following is not a sign of domestic violence? A. Depression B. Weight gain C. Unexplained bruising D. Late initiation of prenatal care Submit Answer

Explanation Choice B is correct. Weight gain is an expected finding in pregnancy and is not a symptom that requires investigation into possible abuse. A woman's risk of becoming a victim of domestic violence increases when pregnant. The health care team should be diligent in watching for signs of violence and abuse in the prenatal client. Choices A, C, and D are incorrect. Depression, unexplained bruising, and late initiation of prenatal care are all signs of possible abuse. Other symptoms include drug or alcohol abuse, chronic pain, and isolation. NCSBN Client need Topic: Maintenance and Health Promotion, Ante / Intra /Postpartum Care Last Updated - 26, Nov 2021

The nurse is caring for a client who is experiencing acute mania. Which of the following actions should be prioritized by the nurse? A. Plan structured solitary activities B. Redirect the client's speech and ideas C. Provide high-calorie, small, frequent meals D. Initiate a psychiatry referral Submit Answer

Explanation Choice C is correct. A patient experiencing acute mania manifests symptoms such as inflated self-esteem, flight of ideas, psychomotor agitation, and an expansive affect. The patient experiencing mania often has difficulty sleeping and exerts excessive physical energy. Thus, the nurse needs to focus on ensuring that the patient's need for nutrition is met by offering high-calorie, small, frequent meals. This is the priority based on Maslow's Hierarchy of Needs. Choices A, B, and D are incorrect. Structured solitary activities are recommended for a patient experiencing mania because group activities may trigger conflict. The nurse should redirect the patient's fragmented speech and ideas as well as consult psychiatry. However, this is not the priority over the patient's physical need for appropriate nutrition. Additional Info When prioritizing client needs, focus on ensuring that the physiological, safety, and security needs are met first. In this question, the patient's physiological and nutritional needs prioritize over the client's need for physical activity. Clients with mania expend a lot of energy and require additional calories. Further, they are unable to sit down and focus on eating a meal. Small, high-calorie, and frequent snacks are recommended. Last Updated - 05, Oct 2022

The nurse is caring for a client who is receiving prescribed acamprosate. Which of the following statements, if made by the client, would indicate a therapeutic response? A. "I no longer hear voices." B. "I have more motivation during the day." C. "I am not drinking alcohol anymore." D. "My anxiety has lessened in public." Submit Answer

Explanation Choice C is correct. Acamprosate is a medication intended to treat alcohol use disorder. This medication may be combined with naltrexone to increase the chance of sobriety. Choices A, B, and D are incorrect. Acamprosate is a medication that may decrease the craving for alcohol. This medication is not an antipsychotic and does not enhance motivation. Further, this medication is not intended for those with anxiety. Additional Info Acamprosate is a prescribed treatment for alcohol use disorder. This medication decreases an individual's craving for alcohol. It is typically dosed three times a day, with the most common side effect being diarrhea. The client should be encouraged to seek counseling to help enhance their chances of abstinence. Last Updated - 11, Dec 2022

A client in a psychiatric clinic tells the nurse, "I want to kill my wife. The moment I see her, I am going to kill her." Which of the following should be the nurse's next action? A. Respect the client's right to privacy and confidentiality. B. Document the client's statements. C. Notify the client's psychiatrist of the comments. D. Explore the client's feelings about his wife. Submit Answer

Explanation Choice C is correct. Confidentiality plays a critical role in client care; however, there may be certain circumstances where confidentiality must be breached to not only ensure the safety of the client, but also to protect a third party (or parties). This concept is referred to as the 'duty to warn' or 'duty to protect.' These types of situations most often arise when a client reports suicidal ideation (SI), homicidal ideation (HI), or when the client makes a threat against an identifiable third party, even if the threat was made during a private therapy session. Choice A is incorrect. As mentioned above, confidentiality plays a critical role in client care; however, there may be certain circumstances where confidentiality must be breached to not only ensure the safety of the client, but also to protect a third party (or parties). Choice B is incorrect. Clear and accurate documentation of the client's statements and the context of the conversation is vital; however, the priority for the nurse is to ensure the safety of the client and the client's wife, likely best achieved by prompt reporting of the client's statements to the client's psychiatric health care provider (HCP). Choice D is incorrect. Assisting the client in exploring their feelings regarding their wife would potentially further increase the client's anger toward her. Therefore, this is not an appropriate action for the nurse to take at this time. Learning Objective When providing care for a client who threatens to kill a third party, recognize that notifying the client's psychiatric health care provider (HCP) of the client's comments is the next action for the nurse to take. Additional Info There is a wide range of 'duty to warn' and 'duty to protect' legal variations across the country, with nurses being impacted in varying degrees. It is crucial for all health care providers (HCPs) of all levels to know the laws in the state(s) in which they practice, as there are significant legal variations from state to state. Failure to know the applicable state statutes and/or regulations may lead to inadvertent violations of the Health Insurance Portability and Accountability Act of 1996. Last Updated - 21, Dec 2022

The nurse is performing an assessment on a client. The client tells the nurse, "You people are part of the government plotting to destroy me." The nurse should respond with which appropriate statement? A. "Would you like me to come back later for your assessment?" B. "I believe you and think we should explore why you feel this way." C. "Tell me more about someone trying to destroy you." D. "Let us talk about your current medication and how it can help with those thoughts." Submit Answer

Explanation Choice C is correct. Exploring the content of the client's delusion is important because this assessment will determine if the delusion has any logic (unlikely) and will help foster a therapeutic relationship with the client. Helping the client come to the realization that the delusion is just that; a delusion can be a challenge. This challenge is often mitigated when a therapeutic rapport is established. Choices A, B, and D are incorrect. Diverting the assessment shows avoidance and is a missed opportunity in intervening in a delusion that may cause a client to react with violence. Avoidance is never therapeutic. Stating that you believe the client is not appropriate. While it is important to explore the client's thought content, validating that someone is after the client, etc., further reinforces the delusion. The nurse should only validate the delusion if it is real. Discussing the treatment plan, while important, does not explore the content of the delusion, which is important. Additional Info Key interventions for a client experiencing a delusion include - Build trust by being open, honest, genuine, and reliable. Respond to suspicion in a matter-of-fact, empathic, supportive, and calm manner. Ask the client to describe their beliefs. Do not use avoidance. Inquire about the delusion and its content. Never debate the delusional content. Validate if part of the delusion is real. Example - "Yes, there was a package at the nurses' station, but it did not contain a recording device." Last Updated - 26, Jul 2022

A client scheduled for hip replacement surgery expresses anxiety to the nurse regarding the upcoming surgery. Which response by the nurse is most therapeutic? A. "Everyone is nervous before any surgery. What you feel is completely normal." B. "Here's what's going to happen to you during the procedure. I will explain it to you in detail." C. "Can you tell me what you have been told about the surgery?" D. "Let me tell you about the care you will receive and the pain you should anticipate after the surgery." Submit Answer

Explanation Choice C is correct. Here, the nurse uses an open-ended question to provide the client with an opportunity to elaborate further on the client's previous statement and provide the nurse with a baseline understanding of the client's knowledge and readiness for the surgery. By ascertaining this information, the nurse can determine the client's current knowledge level and identify relevant educational needs. Here, open-ended questions are the most therapeutic communication technique in this situation as these questions facilitate further discussion. Choice A is incorrect. This response is an example of a nontherapeutic communication technique known as an automated response. Automatic responses are often triggered by stereotypes that are generalized beliefs held about people. These automatic phrases often communicate that the nurse is not taking the client's concern(s) seriously or responding thoughtfully. Choice B is incorrect. This statement by the nurse is nontherapeutic, as it likely offers false reassurance. Although there is a surgical plan, no one (including the nurse) can say with absolute certainty that a surgical procedure will progress in a specific manner. Additionally, the nurse appears to be changing the subject in an attempt to circumvent a conversation regarding the client's anxiety. Choice D is incorrect. This response is an example of nontherapeutic communication, as the nurse appears to be changing the subject once the client attempts to discuss anxiety related to the upcoming hip surgery. Changing the subject when another person is trying to communicate their feelings is impolite, demonstrates a lack of empathy, and blocks further communication. Learning Objective Identify the open-ended question as the most therapeutic response the nurse could provide to the client. Additional Info Therapeutic communication techniques are specific responses that encourage the expression of feelings and ideas and convey acceptance and respect. Nontherapeutic techniques discourage the expression of feelings and ideas and engender negative responses or behaviors in others. Last Updated - 08, Jan 2022

The nurse notices bruises on a client's arm as well as observes that the patient seems afraid and is not speaking much. Since these are possible signs of physical abuse, what is the nurse's most appropriate action? A. Ignore the bruises, as this is not why the patient is being treated, and it is not appropriate for the nurse to address. B. Report the suspected abuse to one of the other nurses and work together on how to handle it. C. Report the findings to the appropriate authorities based on the state requirements and protocols. D. Use therapeutic communication to talk to the patient and attempt to get evidence of suspected abuse. Submit Answer

Explanation Choice C is correct. It is the responsibility of any healthcare provider/team member to report any type of suspected abuse to the police or designated agency, per state policy. Choice A is incorrect. Any signs of suspected abuse should never be ignored but reported to the appropriate agency or police. Choice B is incorrect. Discussing the suspected abuse with another nurse is not indicated. Choice D is incorrect. Although measures to promote therapeutic communication may help get a history from the patient and may lead to the patient disclosing abuse, the nurse is still legally required to report any suspected abuse. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control - Identifying Victims of Violence Last Updated - 11, Nov 2021

A nurse is talking to new volunteers at an elderly community club regarding elder abuse. The nurse identifies which of the volunteer's clients as the one that is most vulnerable to abuse? A. A 75-year-old man that has diabetes B. A 79-year-old man with cataracts C. An 87-year-old woman with Parkinson's disease D. A 64-year-old woman with psoriasis Submit Answer

Explanation Choice C is correct. Most elder abuse victims are females of advanced age and have at least one physical or mental impairment that limits their ability to perform activities of daily living. The client described in choice C is a woman who has Parkinson's disease, which impairs her cognitively. She is also of advanced age, which further makes her susceptible to abuse. Choice A is incorrect. Although this client is elderly, he's a male and has no physical impairment. This client is at a lower risk for elder abuse. Choice B is incorrect. The client is a male with cataracts. Although he has a visual impairment, he is not at significant risk due to his gender and lack of significant mental/physical impairment. Choice D is incorrect. Although her gender puts her at risk of abuse, she does not have any physical or mental impairment, nor does she have an extremely advanced age. Last Updated - 03, Dec 2021

The nurse is preparing a staff development conference on milieu therapy. Which of the following information should the nurse include? A. This type of environment is established in inpatient treatment facilities, emphasizing physical well-being. B. This therapy primarily focuses on helping clients develop emotional connections with individuals in the community. C. An emphasis of this therapy is the setting, the structure, and the emotional climate as important to the client's healing. D. The approach to milieu therapy is unstructured and allows clients to self-regulate what they feel should be allowed. Submit Answer

Explanation Choice C is correct. The cornerstone of milieu therapy is to provide an all-inclusive (staff and clients) structured environment that fosters routine, safety, and acceptance. This environment enables healing and promotes positive outcomes. Choices A, B, and D are incorrect. This type of therapy is not limited to inpatient facilities. This therapy may be established and maintained both inpatient and outpatient. Additionally, milieu therapy is holistic and does not focus just on physical well-being. This therapy aims to provide a safe, structured environment that promotes client healing - not establishing emotional connections with individuals in the community. The approach of the therapeutic milieu is to have structure and consistency that regulates the environment. This allows the client to feel productive, gain self-esteem, and problem solve. Learning Objective Understand that the milieu therapy is an all-inclusive (staff and clients) structured environment that fosters routine, safety, and acceptance. Additional Info Hildegard Peplau referred to the therapeutic milieu as an all-inclusive term that recognizes the people (clients and staff), the setting, the structure, and the emotional climate as essential to healing. Whether the setting involves treating children with psychotic disorders, adult clients in a psychiatric hospital, clients with substance use disorder in a residential treatment center, or clients in a day treatment program. The goal of milieu therapy is to offer clients a sense of security and promotes healing. The nurse can help maintain the therapeutic milieu by Minimizing disruptions in the unit through appropriate client placement Rendering culturally sensitive care Selecting appropriate activities that meet both the physical and mental needs Using the least restrictive environment Last Updated - 23, Apr 2022

A nurse is speaking with the mother of a 3-year-old in the emergency department. After an assessment, the mother is suspected of abusing the toddler. Following a conversation between the nurse and the mother, which finding would most support the suspicion of maternal child abuse? A. The mother exhibits a healthy level of self-esteem. B. The mother describes the happy childhood she experienced. C. The mother complains her toddler seems to be different from others. D. The mother complains that her child seems to be growing up too quickly. Submit Answer

Explanation Choice C is correct. The physical and emotional demands placed on the parent(s) of an unwanted, cognitively impaired, hyperactive, physically disabled, or any other child perceived as "different" may overwhelm the parent(s), resulting in abuse. Choice A is incorrect. Low self-esteem is an identified characteristic that occurs more frequently in parents who abuse children and is therefore considered a risk factor. Here, the conversation resulted in a finding that the mother possesses a healthy self-esteem level. Choice B is incorrect. Often, child abusers were abused themselves or observed some type of abuse in their childhood home(s). Choice D is incorrect. Often, parental fatigue or frustration results in striking out at a child with physical force, shaking a child, or ignoring a child's needs. Here, the mother complains that the child is growing too quickly, implying that she would like to savor this period with the child. In contrast, one would anticipate a fatigued or frustrated parent would want to expedite this period of time. Learning Objective Correlate a parent's viewing of a child as "different" from others as one of the many warning signs of potential child abuse. Additional Info Statistically, abusive families are: socially isolated, have few supportive relationships, are low-income households, and have low levels of education. Younger parents are more likely to abuse their children. Single-parent families are at higher risk for child abuse. Parents with substance abuse problems pose a greater risk for abuse and/or neglect. Parents who grew up with poor parental role models may have difficulty parenting their own children, as parenting skills are learned behaviors. Last Updated - 04, Sep 2022

An LPN is working in a group home for adolescents who are recovering from substance abuse. She is assigned to work with a 16-year-old girl who is trying to quit smoking marijuana. While talking with the girl, she uses motivational interviewing to help her work towards her goals. Which of the following statements by the LPN would be the best? A. "Would it be alright if we talk about your pot use now?" B. "What good things do you have going for you in your life?" C. "What changes can you make in your marijuana use this week?" D. "Who can help you quit marijuana?" Submit Answer

Explanation Choice C is correct. This is a direct, open-ended question that addresses the patient's substance abuse. Motivational interviewing maintains direct communication with open items, as does this question. By using motivational interviewing, the patient should be empowered and encouraged to make positive changes. The nurse will help to facilitate the patient in seeing the need to change, but the patient will make their own decision to work for that change. Choice A is incorrect. If the LPN asks her patient if it is alright to talk about her substance abuse, it allows the patient to say no. This could prevent the LPN from having a productive conversation with her patient and will not likely be an excellent motivational interviewing conversation. Choice B is incorrect. This is an off-topic question and does not directly address the patient's substance abuse. The LPN should use open-ended questions that directly address the patient's substance abuse to begin motivational interviewing. Choice D is incorrect. This is not an appropriate statement because it does not focus on the patient. Instead, it seeks to involve another person. This will not aid in helping the patient feel empowered to make their positive changes, which is what motivational interviewing seeks to do. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Mental Health - Substance Abuse Last Updated - 11, Feb 2022

You are working as a school nurse in a local high school. One of the students frequently presents to your office with a fever, runny nose, nausea, vomiting, and dilated pupils. What do you suspect is most likely happening with this high school student? A. Inhalant abuse B. Barbiturate abuse C. Oxycodone abuse D. Viral infection Submit Answer

Explanation Choice C is correct. You most likely suspect that this high school student is abusing an opioid drug such as oxycodone. Fever, runny nose, excessive yawning, nausea, vomiting, and dilated pupils are some of the signs associated with opiate withdrawal. Based on the presentation, it appears like the student is abusing opioids potentially after school and now showing early withdrawal signs. Withdrawal symptoms may present just after 8 to 12 hours in clients with a history of chronic opioid abuse. Symptoms of Opioid Withdrawal: Early symptoms and signs of opioid withdrawal include diaphoresis, nausea, yawning, lacrimation, tremor, rhinorrhea, agitation, dilated pupils, and increased pulse rate at greater than 90. These early withdrawal symptoms start 8-12 hours after the last dose. Late signs of opioid withdrawal are more severe and include nausea with vomiting, abdominal cramps, diarrhea, chills, insomnia, dilated pupils, tachycardia, tachypnea, and hypertension. Opioid overdose may present with symptoms opposite to those of withdrawal. These include slurred speech, respiratory depression, hypotension, drowsiness, and constricted pupils. However, a client with an opioid overdose is likely to present to the emergency department rather than attending school. The nurse should be aware of the effects of various drugs on the pupil size because it may help determine the substance being abused. Opioid overdose is the only condition that is associated with pupillary constriction (pinpoint pupils). The substance-abuse conditions that are associated with pupillary dilation include: Use of CNS stimulants: Marijuana (Cannabis); Amphetamines (MDMA, Ecstasy), Cocaine, Mescaline, SSRIs (Selective Serotonin Reuptake Inhibitors), Hallucinogens (mescaline, LSD, psilocybin) Withdrawal of opioids (i.e. Heroin withdrawal) Choice A is incorrect. An inhalant abuse should be suspected in a client who is demonstrating slurred speech, uncoordinated movements, and stupor. Such symptoms can also be seen with opioid overdose. Pupil size tends to be normal in an inhalant overdose or withdrawal. Choice B is incorrect. Withdrawal from barbiturate abuse or other CNS depressant abuse should be suspected if the client is presenting with withdrawal symptoms of nausea, vomiting, insomnia, hyperreflexia, anxiety, tremors, seizures, hallucinations, and psychomotor agitation. Pulse and respiratory rate may increase. Fever may be seen in barbiturate withdrawal. Symptoms of barbiturate withdrawal develop 24-36 hours after the last dose. However, dilated pupils are not a manifestation of barbiturate withdrawal and serve as a differentiator from opioid withdrawal. Barbiturate overdose also does not affect pupil size. If the pupils are dilated in a barbiturate overdose patient, that is from secondary anoxia rather than the drug itself. Choice D is incorrect. Although fever is a distractor, this presentation is not consistent with an infection because of the frequent occurrence over the last one month and the presence of dilated pupils. Last Updated - 25, Jan 2022

The school nurse has performed an assessment on a 6-year-old child who has been sent to the office after a teacher developed concerns for his safety. Which findings will lead the nurse to investigate other signs of neglect? A. The child has a difficult time paying attention during class. B. The child always finishes his meal at lunch time and is hungry again a few hours later. C. The child is more shy than many of his classmates. D. The child is frequently absent from school and is tired when he does attend. Submit Answer

Explanation Choice D is correct. A child who is frequently absent from school and fatigued should be further investigated for neglect at home. Other signs may be poor dental hygiene, lack of appropriate seasonal clothing, or a tendency towards theft. Choice A is incorrect. Many children have difficulty paying attention to their teachers at this age and are not necessarily being neglected. Choice B is incorrect. Children at this age will need to eat every few hours. Eating their lunch and finding themselves hungry a few hours later is an expected finding. Choice C is incorrect. Shyness is not necessarily a sign of neglect. All children have different personalities and will express themselves differently in the classroom. NCSBN client need Topic: Psychosocial Integrity, Abuse/Neglect Last Updated - 06, Jan 2022

The nurse suspects that the patient being treated for chronic stomach discomfort may be abusing alcohol. Which of the following is not a screening tool for alcohol abuse? A. CAGE B. TWEAK C. AUDIT-C D. ALCH Submit Answer

Explanation Choice D is correct. ALCH is not a screening tool for alcohol abuse. Choice A is incorrect. CAGE is a very common screening tool for alcohol abuse. CAGE stands for: Has anyone ever told you that you need to Cut down on drinking? Have you ever felt Annoyed when criticized about your drinking? Have you ever felt Guilty about your drinking? Do you ever feel the need for an Eye-opener in the morning? Choice B is incorrect. TWEAK is another common screening tool that addresses tolerance, worry, eye-openers, amnesia, and feeling the need to cut down on drinking habits. Choice C is incorrect. AUDIT-C is a screening tool that looks at much of the same issues yet uses fewer questions with a sliding scale scoring technique. Last Updated - 24, Jan 2022

A 6-year-old is admitted to the hospital for multiple fractures and is subsequently identified as a victim of child abuse. A community health nurse (CHN) is assigned to the child following discharge from the hospital. Which characteristics would the CHN expect to see from the child? A. The child displays appropriate behaviors during each encounter. B. The child seeks to contact his or her parents. C. The child becomes an overachiever in school and displays advanced developmental growth. D. The child becomes aloof and isolated from peers. Submit Answer

Explanation Choice D is correct. Abused children have difficulty in social situations with peers. The effect of abuse on children becomes more apparent when the child reaches school age. At this point, difficulties develop in forming relationships with both peers and teachers. Choice A is incorrect. A victim of child abuse is likely to display inappropriate behavior in every (or nearly every) situation due to delayed development of social skills, insecurity, anxiety, or distrust. Choice B is incorrect. An abused child will often appear fearful and withdrawn from one or both caregivers involved in abusing the child. Choice C is incorrect. Abuse and neglect are often associated with physical injuries, delayed growth and development, and mental problems. These issues often result in lackluster performances at school. Learning Objective Recognize that a community health nurse would anticipate a child exhibiting aloofness and isolation from peers following hospital discharge after an episode of child abuse. Additional Info Generally, abuse can be attributed to a breakdown of impulse control in the parent or caregiver. The parent's childhood may have lacked affection and warmth, may not have been conducive to the development of adequate self-esteem or emotional maturity, and, in many cases, also included other forms of maltreatment or abuse. Drug or alcohol use may provoke impulsive and uncontrolled behaviors toward their children. Parental mental disorders also increase the risk of abuse. Last Updated - 25, Sep 2022

The nurse is interviewing a client in the clinic looking to establish care. The nurse determines the client is demonstrating altruism by A. justifying illogical ideas, actions, or feelings by developing acceptable explanations. B. reverting to an earlier, more primitive, and childlike pattern of behavior. C. channeling anger from an unacceptable activity to one that is acceptable. D. a largely unconscious motivation to feel caring and concern for others. Submit Answer

Explanation Choice D is correct. Altruism is generally a positive defense mechanism that, when utilized appropriately, causes an individual to feel caring and concern for others and act for the well-being of others. Although this defense mechanism is generally regarded as a positive one, it may be maladaptive if a client threatens the health or safety of themselves or others (for example, a client adopts several stray animals, but it threatens the health of others in the household). Choices A, B, and C are incorrect. Justifying illogical ideas, actions, or feelings by developing acceptable explanations is the definition of rationalization. Reverting to an earlier, more primitive, and childlike pattern of behavior refers to regression. Finally, sublimation is channeling anger from an unacceptable activity to one that is acceptable. Additional Info Adaptive use of defense mechanisms helps people to lower their levels of anxiety and to achieve their goals in acceptable ways. Maladaptive use of defense mechanisms occurs when one or several are used to excess, particularly immature defenses. Most defense mechanisms can be used in both healthy and unhealthy ways. People generally use a variety of defense mechanisms but not always to the same degree. Last Updated - 21, Jun 2022

The nurse is caring for a client experiencing delirium tremens. The nurse anticipates a prescription for which medication? A. Disulfiram B. Naloxone C. Methadone D. Clonidine Submit Answer

Explanation Choice D is correct. DTs can be fatal if untreated. DTs result from florid alcohol withdrawal causing the client to experience hallucinations, hypertension, agitation, nystagmus, and potential seizure activity. Clonidine is an alpha-agonist and is primarily used in the treatment of hypertension. Clonidine is helpful during DTs because it lowers the client's blood pressure and gives the client some drowsiness which is useful if they are agitated. Choices A, B, and C are incorrect. Disulfiram is a conventional medication prescribed to prevent an individual from drinking. It has no indication during acute alcohol withdrawal. Disulfiram is a negative reinforcer because when a client ingests alcohol, it causes headaches, nausea, and vomiting. Naloxone is used in emergent situations for opioid toxicity. Methadone is a highly effective treatment used for opioid use disorder. Additional Info ✓ Delirium Tremens (DTs) are a medical emergency and may cause autonomic hyperactivity, resulting in tachycardia, diaphoresis, fever, anxiety, insomnia, and hypertension. ✓ Delusions and visual and tactile hallucinations are common in alcohol withdrawal delirium. ✓ This may occur within 72 hours following the last alcoholic beverage consumed. ✓ Withdrawal seizures may occur within 12 to 24 hours after alcohol cessation. ✓ These seizures are generalized and tonic-clonic. Additional seizures may occur within hours of the first seizure. ✓ Diazepam is given intravenously as a common treatment for withdrawal seizures. Nursing care for DTs includes - Rapid assessment of the client's vital signs Initiate seizure precautions and establish patent intravenous access Obtain a prescription for benzodiazepines, such as lorazepam or diazepam Administer intravenous fluids and electrolytes to replete the lost fluids Assess the client using the CiWa-Ar scale to trend the severity of the symptoms Last Updated - 03, Feb 2023

The emergency department nurse (ED) prepares to care for a client with severe anxiety. The nurse anticipates that the client will demonstrate A. limited problem solving and decreased attentiveness. B. heightened perceptual field and is aware of the anxiety. C. narrowed perceptual field and able to discuss past coping mechanisms. D. the inability to problem solve and has a sense of impending doom. Submit Answer

Explanation Choice D is correct. Severe anxiety may lead to physical exhaustion if prompt intervention is not obtained. Severe anxiety is marked by - Greatly reduced and distorted perceptual field Focuses on details or one specific detail Attention is scattered Inability to problem solve The feeling of impending doom Choices A, B, and C are incorrect. Limited problem-solving, narrowed perceptual field, and decreased attentiveness best explain moderate anxiety. When a client has a heightened perceptual field and is aware of the anxiety, this is fitting of mild anxiety. Additional Info Mild Anxiety This type of anxiety occurs during everyday living and allows an individual to perceive reality in sharp focus. A person experiencing a mild level of anxiety sees, hears, and grasps more information, and problem-solving becomes more effective. Physical symptoms may include slight discomfort, restlessness, irritability, or mild tension-relieving behaviors (e.g., nail-biting, foot or finger tapping, fidgeting). Moderate Anxiety As anxiety increases, the perceptual field narrows, and some details are excluded from observation. The person experiencing moderate anxiety sees, hears, and grasps less information and may demonstrate selective inattention, inhibiting problem-solving. More intense physical symptoms may be present, which include increased pulse and respiratory rates, perspiration, and mild somatic symptoms (e.g., gastric discomfort, headache, urinary urgency). Severe/Panic Anxiety The perceptual field of a person experiencing severe anxiety is greatly reduced. A person with severe anxiety may focus on one particular detail or on many scattered details and have difficulty noticing what is going on in the environment, even when another person points it out. Learning and problem solving is not possible at this level, and the person may be dazed and confused. Significant physical symptoms may be event including hyperventilation, palpitations, and headache. Hospitalization may be required for this level of anxiety. Last Updated - 02, Nov 2022

Upon interviewing the peers of a teenage client diagnosed with anorexia nervosa, a nurse would anticipate the friends to describe the client as which of the following? A. An underachiever B. Disorderly C. Independent D. Obedient Submit Answer

Explanation Choice D is correct. Teenage clients with anorexia nervosa continually strive for perfection in all they do, exhibiting obedient and orderly behavior at home and school. Choice A is incorrect. The overwhelming majority of teenage clients with anorexia nervosa are overachievers, possessing very high standards for achievement and success. Choice B is incorrect. Teenage clients with anorexia nervosa are rule-driven and strive for perfectionism in all they do. Choice C is incorrect. Studies have demonstrated a statistically significant link between interpersonal dependency (i.e., the reliance on others for physical and/or psychosocial needs) and anorexia nervosa. Learning Objective Anticipate the peers of an anorexic teenage client to describe the client as "obedient" when asked. Additional Info Clients with anorexia nervosa frequently have coexisting psychiatric disorders (diagnosed or undiagnosed), including, but not limited to, affective disorder, anxiety disorder, obsessive-compulsive disorder, and/or personality disorders. Individuals with eating disorders have also been found to have higher reported rates of substance abuse (with alcohol problems being more common in those with bulimia nervosa than anorexia nervosa). Source : Archer ReviewSource : Archer Review Last Updated - 04, Sep 2022

Your client has been diagnosed with chronic pancreatitis secondary to alcohol abuse. Which of the following is the most appropriate tertiary prevention expected outcome for this client? A. Altered digestion is secondary to pancreatitis. B. Altered coping secondary to alcoholism. C. The client will be free of insomnia during hospitalization. D. The client will participate in a 12 step recovery program. Submit Answer

Explanation Choice D is correct. The client participating in a 12 step recovery program is the most appropriate tertiary prevention expected outcome since they have been diagnosed with chronic pancreatitis secondary to alcohol abuse. Tertiary prevention includes rehabilitation, so a 12 step recovery program is a form of this. Choice A is incorrect. Altered digestion secondary to pancreatitis is a physiological nursing diagnosis and not an expected outcome or client goal. Choice B is incorrect. Altered coping secondary to alcoholism is a psychological nursing diagnosis and not an expected outcome or client goal. Choice C is incorrect. The client being free of insomnia during hospitalization is a possible outcome. However, insomnia during hospitalization is a secondary, rather than a tertiary, prevention expected outcome or client goal. Additional Info Last Updated - 01, Feb 2022

The nurse is caring for a client with a history of aggressive and violent behavior. When caring for this client, the nurse should initially take which action? A. Restrain the client B. Place the client in seclusion C. Get an order for a sedating medication D. Establish trust with the client Submit Answer

Explanation Choice D is correct. The first thing the nurse should do to prevent violence is to establish trust with the client. The first step in the nurse-client relationship is to build confidence in this therapeutic relationship. Without trust, future collaboration, interventions, and client outcomes cannot facilitate appropriate and safe behaviors. Choices A, B, and C are incorrect. Restraints (physical and chemical) and seclusion are restrictive and not the first intervention to prevent violence. Seldomly, these interventions may need to be utilized; however, the nurse should always strive to have a therapeutic rapport with the client predicated on trust. Additional Info Deescalation Techniques: Practice Principles • Maintain the client's self-esteem and dignity • Maintain calmness (your own and the clients) • Assess the client and the situation • Identify stressors and stress indicators • Respond as early as possible • Use a calm, clear tone of voice • Invest time • Remain honest • Determine what the patient considers to be needed • Identify goals • Avoid invading personal space; in times of high anxiety, personal space increases • Avoid arguing • Give several clear options • Use genuineness and empathy • Be assertive (not aggressive) • Do not take chances; maintain personal safety Halter, M. (082021). Varcarolis' Foundations of Psychiatric-Mental Health Nursing, 9th Edition. Last Updated - 22, Nov 2022

The nurse is developing group therapy sessions on substance use disorders. The nurse develops weekly topics and plans to host the sessions in a community center. The nurse is in which phase of therapeutic group development? A. Working B. Orientation C. Termination D. Planning Submit Answer

Explanation Choice D is correct. The nurse is in the planning phase, and the crux of this phase is to identify the purpose of the group, its objectives, individuals who may attend, and weekly topics. Choices A, B, and C are incorrect. The working phase is when the group performs the work, such as communicating with others, doing therapeutic exercises, and strengthening their rapport. The orientation phase is when the nurse ensures that group members feel welcome and understand the group's purpose. Termination is when the nurse recaps the group's successes and future goals. Additional Info ✓ Therapeutic groups have four phases: planning, orientation, working, and termination. ✓ The planning phase deals with the nurse planning the name of the group, its objectives, types of individuals, setting, and schedule. The nurse should plan a group that involves members that are ready to join. Thus, individuals with psychosis or mania would be inappropriate for therapeutic groups. ✓ The orientation phase deals with the nurse introducing the group, the structure, its purpose, and when the group is to be terminated. The nurse should encourage rapport-building during this phase. ✓ The working phase is when the nurse facilitates problem-solving. The problem-solving should be focused and align with the group's purpose. The nurse should ensure that all members have equality regarding a group's discussion. ✓ The termination phase is when the nurse summarizes the accomplishments and future goals. Some individuals may have difficulty during this phase. To ensure a smooth termination phase, the nurse should inform group participants of when the group will terminate (after three sessions, etc.) during the orientation phase. Participants may exhibit a sense of hostility during this phase if they are not ready to let go. Last Updated - 31, Jan 2023

A patient presents to the emergency department with pinpoint pupils, poor attention, and slurred speech. Upon assessment of vitals, the patient is found to have a BP of 92/60 mmHg, HR 58, RR 14, and T 96.8 degrees F. Which substance is this patient's intoxication most likely related to? A. Alcohol B. Cannabis C. Cocaine D. Opiates Submit Answer

Explanation Choice D is correct. The patient is showing signs of opiate intoxication. Opiate intoxication is characterized by pinpoint pupils, slurred speech, inattention, lethargy, psychomotor retardation, and impaired memory, judgment, and social function. Changes to vitals include hypotension, decreased heart rate, reduced temperature, and lower respiratory rate. Choice A is incorrect. Alcohol intoxication is characterized by unsteady gait/balance, nystagmus, flushed face, sedation, impaired judgment, uninhibited behavior, talkativeness, slurred speech, impaired memory, and irritability. Choice B is incorrect. Cannabis intoxication is characterized by reddened eyes, increased heart rate, dry mouth, hunger, loss of coordination/balance, relaxed mood, increased perceptions, social withdrawal, and paranoia. Choice C is incorrect. Cocaine intoxication is characterized by pupil dilation, increased or decreased heart rate and blood pressure, chills, nausea/vomiting, sweating, pacing, psychomotor agitation, visual or tactile hallucinations, and hyper-vigilance. NCSBN Client Need Topic: Pharmacology, Subtopic: Chemical and other dependencies/substance use disorder, high-risk behaviors, lifestyle choices Last Updated - 10, Jan 2022

The nurse is leading a group therapy session on substance use disorders. The nurse observes that a client is monopolizing the session. The nurse should take which appropriate action? A. Ask the client to leave the therapy session B. Stop the session to review the rules with the group C. Allow the client to express themselves uninterrupted D. Ask the group if they would like to share their observations about other members Submit Answer

Explanation Choice D is correct. This is an appropriate action because it addresses the problem and allows the group to engage in problem-solving, which is the crux of group therapy. The nurse should solicit feedback from other group members on how they feel the group is going or share observations. This tactic, while challenging, promotes problem-solving and reflection, both of which are essential in therapy. Choices A, B, and C are incorrect. Asking the client to leave the session is inappropriate and would ultimately delay the client's ability to meet their therapeutic goals. The client needs to recognize that they are monopolizing the group and that leaving would not have any benefit. The nurse should not stop the session because that would further magnify the disruption, and stopping the session would cause unnecessary delay for the other group members. The nurse needs to address the behavior, so the rest of the group can be productive. Thus, the nurse needs to address the behavior diplomatically. Additional Info ✓ Therapeutic groups have four phases: planning, orientation, working, and termination. ✓ The planning phase deals with the nurse planning the name of the group, its objectives, types of individuals, setting, and schedule. The nurse should plan a group that involves members that are ready to join. Thus, individuals with psychosis or mania would be inappropriate for therapeutic groups. ✓ The orientation phase deals with the nurse introducing the group, the structure, its purpose, and when the group is to be terminated. The nurse should encourage rapport-building during this phase. ✓ The working phase is when the nurse facilitates problem-solving. The problem-solving should be focused and align with the group's purpose. The nurse should ensure that all members have equality regarding a group's discussion. ✓ The termination phase is when the nurse summarizes the accomplishments and future goals. Some individuals may have difficulty during this phase. To ensure a smooth termination phase, the nurse should inform group participants of when the group will terminate (after three sessions, etc.) during the orientation phase. Participants may exhibit a sense of hostility during this phase if they are not ready to let go. Last Updated - 02, Feb 2023

The nurse is assessing client who has a borderline personality disorder (BPD). Which of the following would be an expected finding? Select all that apply. A. Self-mutilating behaviors B. Hypervigilance C. Emotional detachment D. Social inhibition E. Impulsivity Submit Answer

Explanation Choices A and E are correct. Borderline personality disorder (BPD) is a common personality disorder that features extreme emotional lability, impulsivity, self-mutilative behaviors, and manipulative mannerisms. Choices B, C, and D are incorrect. Hypervigilance is an expected finding with a paranoid personality disorder. Emotional detachment is compatible with a schizoid personality disorder. Social inhibition is consistent with an avoidant personality disorder. Additional Info A borderline personality disorder is about five times more common in first-degree biological relatives with the same disorder compared with the general population. This disorder is highly associated with genetic factors such as hypersensitivity, impulsivity, and emotional dysregulation. A key intervention for a client with BPD is to assess for suicidality. Parasuicide is common with this personality disorder; however, it is essential to keep this client safe. Defense mechanisms commonly seen in this personality disorder include splitting, projective identification, and denial. Last Updated - 27, Oct 2021

The nurse is assessing a client with Antisocial Personality Disorder. Which of the following would be an expected finding? Select all that apply. A. Lack of empathy B. Grandiosity C. Preoccupation with orderliness D. Excessive attention-seeking E. Disregard for the right of others Submit Answer

Explanation Choices A and E are correct. Individuals with Antisocial Personality Disorder have clinical features such as a disregard for others, deception, lack of empathy, and a failure to conform to societal norms. Choices B, C, and D are incorrect. Grandiosity is a clinical feature central to narcissistic personality disorder. A preoccupation with orderliness is a key feature associated with an obsessive-compulsive personality disorder. Excessive attention-seeking is a cardinal feature associated with a histrionic personality disorder. Additional Info Antisocial personality disorder has clinical features such as superficial charm, deceit, failure to follow societal norms, and the inability to demonstrate empathy. Client management involves setting limits and maintaining a structured environment. The nurse should ensure that the environment is safe because an individual with an antisocial personality disorder may be impulsive and act out with anger. No medication is approved/indicated for this disorder; however, early intervention with psychotherapy is helpful. Last Updated - 07, Feb 2022

The nurse has provided medication instruction to a client who has been prescribed methadone for opioid use disorder. Which of the following statements, if made by the client, would indicate a correct understanding of the instructions? Select all that apply. A. "I will need counseling while taking this medication." B. "I will need periodic blood tests while on this medication." C. "This medication may lower my risk for Hepatitis C." D. "This medication will send me into opioid withdrawals." E. "I may get drowsy while taking this medication."

Explanation Choices A, B, C, and E are correct. Methadone is an efficacious medication used in the treatment of opioid use disorder, chronic pain, and in the treatment of neonatal abstinence syndrome. This medication requires close monitoring and counseling for opioid use disorder. Periodic blood tests are required as this medication may be hepatotoxic. This medication has been shown to decrease the transmission of blood-borne pathogens such as HIV and Hepatitis C. This is because the reduction of intravenous drug use decreases the risk of the transmission of these pathogens. Drowsiness is a common side effect of this medication as it is an opioid agonist. Choice D is incorrect. This medication does not precipitate opioid withdrawal as this medication is an opioid agonist - not an antagonist. This medication may assist with withdrawal symptoms. Additional Info Treatment for opioid use disorder includes naltrexone, methadone, or buprenorphine. These medications have proven efficacy in this disorder, and when combined with counseling and appropriate monitoring, they may assist a patient in attaining opioid abstinence. Last Updated - 16, Oct 2021

Which statements about therapeutic communication are accurate? Select all that apply. A. Therapeutic communication is goal-oriented, purposeful, caring, and compassionate. B. Therapeutic communication occurs after trust is established in the nurse-client relationship. C. Therapeutic communication occurs between the nurse and other members of the nursing team. D. Therapeutic communication consists of only oral communication that is understandable. E. Therapeutic communication must be modified and altered according to the client's culture. F. Therapeutic communication is fully mindful of any nonverbal messages that are sent by the nurse. Submit Answer

Explanation Choices A, B, E, and F are correct: Choice A is correct. Therapeutic communication is goal-oriented, purposeful, caring, and compassionate. The purpose of therapeutic communication is to facilitate the achievement of optimal client outcomes. Therefore, they must be caring and kind to achieve this goal. Choice B is correct. Therapeutic communication occurs after trust is established in the nurse-client relationship. The therapeutic nurse-client relationship begins with the establishment of trust with the client, after which the working phase of the therapeutic nurse-client relationship can continue with ongoing, open, and honest communication. Choice E is correct. Therapeutic communication must be modified and altered according to the client's culture. Many factors, including culture, impact the therapeutic communication process. Additional factors that impact the therapeutic communication process include age, level of development, perspectives, and values. Choice F is correct. Therapeutic communication is fully mindful of any nonverbal messages that are sent by the nurse. Therapeutic communication consists of both oral communication that is understandable to the client as well as nonverbal communication techniques that are consistent with the received message as well as the client's needs. Choices C and D are incorrect: Choice C is incorrect. Therapeutic communication occurs between the nurse and the client or groups of clients. Although nurses communicate with other members of the nursing team in a respectful, open, and honest manner, this communication is considered professional communication and not therapeutic communication. Choice D is incorrect. Therapeutic communication consists of both oral communication that is understandable to the client as well as nonverbal communication techniques that are consistent with the received message as well as the client's needs. Last Updated - 02, Feb 2022

The nurse is teaching a group of students about using reminiscence therapy. Which statements should the nurse include in the teaching? Select all that apply. A. This approach helps support self-esteem B. This is an effective intervention in a group setting C. This intervention focuses on looking forward D. Establishing future goals is important part of this intervention E. Reminiscing is a way to express personal identity Submit Answer

Explanation Choices A, B, and E are correct. Reminiscence helps support self-esteem by having an individual look back on past accomplishments and positive life experiences. This strategy may be used one-on-one or in a group setting, facilitating rapport building with other individuals. Finally, reminiscence is a way for an individual to express their personal identity by reflecting on past accomplishments (college work, occupations, marriage, etc.). Choices C and D are incorrect. Reminiscence is about looking at the client's past to support their self-esteem by expressing previous experiences. This therapeutic approach does not involve goal setting or forward-looking approach. Additional Info Reminiscence is a therapeutic measure that enables an individual to recall past memories. Many older adults enjoy sharing past experiences through storytelling. As a therapy, reminiscence uses the recollection of the past to bring meaning and understanding to the present and resolve current conflicts. This approach also supports an individual's self-esteem by reflecting on positive events. Last Updated - 19, Nov 2022

The nurse is assessing a client with opioid withdrawal. Which of the following would be an expected finding? Select all that apply. A. Diaphoresis B. Bradycardia C. Irritability D. Hypotension E. Rhinorrhea F. Abdominal cramps Submit Answer

Explanation Choices A, C, E, and F are correct. A client experiencing opioid withdrawal will experience symptoms such as abdominal cramping, diarrhea, nausea, rhinorrhea, piloerection, diaphoresis, tachycardia, hypertension, insomnia, and agitation. Choices B and D are incorrect. Bradycardia and hypotension are expected findings during opioid intoxication. Opioids are central nervous system (CNS) depressants and may cause life-threatening hypotension, bradycardia, and bradypnea. Additional Info Opioid withdrawal is typically not life-threatening but highly uncomfortable for the client. Treatment is symptomatic, including encouraging hydration if the client is experiencing vomiting or diarrhea. The nurse should advocate for treatment options to promote abstinence from opioids, such as pharmacotherapy (methadone, naltrexone, etc.) and/or psychotherapy. Last Updated - 28, Dec 2022

You are taking care of a 45-year-old female who is being treated with electroconvulsive treatment (ECT) for severe depression. After her treatment today, which of the following nursing interventions are appropriate? Select all that apply. A. Position her supine with the head of the bed at 30 degrees B. Reorient the patient frequently C. Remain with the patient at all times D. Promote bedrest for 12-24 hours Submit Answer

Explanation Choices B and C are correct. It will be a very important nursing intervention to frequently reorient the patient who has just received electroconvulsive therapy (ECT). This is because temporary memory loss is associated with this procedure, so they will likely be very confused and disoriented. Due to this disorientation, they will likely be scared; to make them feel safe and secure the nurse will need to frequently reorient them to their place and situation (Choice B). It will be a very important nursing intervention to remain with the patient who has just received electroconvulsive therapy. A side effect of electroconvulsive therapy is temporary memory loss. They will be disoriented and confused, so the nurse must remain with them at all times to keep them safe (Choice C). Choice A is incorrect. Supine with the head of the bed at 30 degrees is not the best position for a patient who has just had electroconvulsive therapy. This patient is at risk for aspiration, so the appropriate positioning is on her side. This will prevent anything from entering her airway and causing an aspiration event. Supine with the head of the bed at 30 degrees would be the appropriate positioning for a patient post-op from neurosurgery or at risk for increased ICP. Choice D is incorrect. It is not necessary or appropriate to promote bedrest for 12-24 hours in the patient who has just received electroconvulsive therapy. After they are awake and re-oriented, it is best to promote activity and get them back to their normal routine. Staying active is an important part of treating depression, so bed rest is not appropriate for this patient. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Psychiatric Nursing Last Updated - 10, Feb 2022

The nurse is caring for a client experiencing an acute episode of severe anxiety. The nurse should plan to take which appropriate action? Select all that apply. A. Discuss previous coping skills B. Stay and observe the client C. Maintain an environment with low stimuli D. Plan to ambulate with the client in the hallway E. Instruct the client to identify what triggered the event F. Assess the client for possible hypoventilation G. Obtain a prescription for haloperidol Submit Answer

Explanation Choices B and C are correct. Severe anxiety causes an individual to experience a narrow perceptual field, an inability to problem-solve, and somatic symptoms such as dizziness, palpitations, diaphoresis, and a feeling of impending doom. Staying with the client provides an assurance and enables the nurse to give the client simple and short directions, if necessary. Choices A, D, E, F, and G are incorrect. Discussing previous coping skills is not an intervention appropriate for a client experiencing severe anxiety. This level of anxiety prevents a client from appropriately reflecting and conversing about what triggered the anxiety and previous coping skills. The environment should be a low stimulus and ambulating the client in the hallway would exacerbate the anxiety because of the sounds and stimuli. If a client is experiencing this level of anxiety, hyperventilation is more likely to occur, which could cause the client to develop dizziness. Finally, if prescriptive interventions are necessary, haloperidol would be inappropriate because it is an antipsychotic. Antipsychotics have no utility in the management of anxiety. For an acute episode of anxiety, medications such as benzodiazepines (alprazolam) or antihistamines (hydroxyzine) may be indicated. Additional Info Source : Archer Review Severe anxiety is marked by - Greatly reduced and distorted perceptual field Focuses on details or one specific detail Attention is scattered Inability to problem solve A feeling of impending doom Interventions include staying with the client because their behavior may become unpredictable, coaching breathing if the client develops hyperventilation, giving the client short and simple cues, and obtaining prescriptive medication (if necessary). The nurse should ensure that the environment is tranquil and does not have excessive stimuli.

The nurse is caring for a client who is demonstrating signs of aggression. The nurse should plan to take which action? Select all that apply. A. Use therapeutic touch B. Use genuineness and empathy C. Use a calm, clear tone of voice D. Talk with the client in a closed private room E. Give several clear options F. Respond as early as possible Submit Answer

Explanation Choices B, C, E, and F are correct. For a client demonstrating aggression, the nurse should respond quickly and calmly approach the client. The nurse should limit inflections in their voice to decrease the perception of aggression. The nurse should also maintain personal distance between themselves because if this escalates, the nurse has an appropriate distance from themselves and the client. Providing the client with several options is helpful as it decreases the client's feeling of powerlessness. Choices A and D are incorrect. The nurse should not use therapeutic touch when dealing with an aggressive client. This would be misconstrued as aggression on the nurse's part. The nurse should confer with the client in an area with minimal stimulation but not in a closed private room. This space may allow the client to physically assault the nurse without others noticing. Additional Info Deescalation Techniques: Practice Principles • Maintain the client's self-esteem and dignity • Maintain calmness (your own and the clients) • Assess the client and the situation • Identify stressors and stress indicators • Respond as early as possible • Use a calm, clear tone of voice • Invest time • Remain honest • Determine what the patient considers to be needed • Identify goals • Avoid invading personal space; in times of high anxiety, personal space increases • Avoid arguing • Give several clear options • Use genuineness and empathy • Be assertive (not aggressive) • Do not take chances; maintain personal safety Halter, M. (082021). Varcarolis' Foundations of Psychiatric-Mental Health Nursing, 9th Edition. Last Updated - 22, Nov 2022

After failing a final anatomy exam, a student is angry with the instructor and talks negatively about her. What defense mechanism is this an example of? A. Acting out B. Projection C. Compensation D. Reaction-formation Submit Answer

Explanation Choice B is correct. The client is placing blame on others and not taking responsibility for her behavior. Choice A is incorrect. Acting out is not a defense mechanism. Choice D is incorrect. Reaction-formation is preventing "dangerous" feelings from being expressed by exaggerating the opposite attitude. Choice C is incorrect. Compensation is covering up a weakness by emphasizing a desirable trait. Acting out is not a defense mechanism. NCSBN Client Need Topic: Psychosocial Development, Subtopic: Defense Mechanisms Additional Info Last Updated - 14, Feb 2022

A nursing student is currently learning about domestic violence and wonders why the abused individual cannot "just quickly get out of the relationship." Which theoretical model helps in explaining the cyclical and progressive nature of domestic and spousal abuse? A. The Cycle of Abuse and Neglect B. The Cycle of Violence C. The Cycle of Impaired Couples D. The Duluth Model Submit Answer

Explanation Choice B is correct. The cycle of violence is a model developed in 1979 by Lenore Walker to explain the co-existence of disorder with love. It may be tough for those who have never experienced domestic abuse to understand why it is difficult for an abused individual to "just quickly leave" the relationship. Understanding the cycle of violence may help plan appropriate interventions to break the cycle and stop domestic violence. Violence often occurs in a repetitive cycle and usually consists of three phases: (1) the Tension phase, (2) the Acute explosion phase (Crisis phase), and (3) the Honeymoon Phase (calm phase). In the first phase (tension-building), the abuser gets angry, argumentative, and starts threatening. Minor fights may occur. In this phase, victims often report a feeling of walking on eggshells. As the period progresses, tension continues to build. In the second phase (explosion/crisis), significant verbal or physical abuse will occur. Major violent acts such as physical or sexual attacks will follow and may result in injury. In the third phase (Calm phase or Honeymoon period), the abuser expresses sorrow and feelings of guilt. The abuser shows love and promises to change and get himself/herself help. The victim feels like things are getting much better, but the phase does not last. The cycle starts all over again and the three steps repeat over time. It is, therefore, hard to end an abusive relationship since the three phases of love, hope, and fear, keep the cycle moving. The cycle is progressive as well. With every period, the abuse may get worse during the explosion phase. Choices A and C are incorrect. These cycles are non-existent and do not predict the progressive nature of domestic abuse. Choice D is incorrect. The Duluth Domestic Abuse Intervention Project, also called "the Duluth Model," is a model that was developed in the 1980s for guiding intervention in domestic violence. Contrary to the cycle of violence, the Duluth model maintains that the force is not cyclical but constant. The acts of violence are intentional and the motivation for violence is to exert power and control over the victim. The image below shows the "Power and Control" wheel put forward by the Duluth Model. NCSBN Client Need Topic: Psychosocial Integrity; Subtopic: Abuse/Neglect Last Updated - 10, Feb 2022

The nurse is assessing a client with possible bipolar I disorder. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which laboratory testing? A. Thyroid Stimulating Hormone (TSH) [39%] B. Complete Metabolic Panel (CMP) [47%] C. Glycated Hemoglobin A1C (HbA1c) [3%] D. C-Reactive Protein (CRP) [11%]

Explanation Choice A is correct. A TSH is the standard of care before diagnosing a mood disorder such as bipolar disorder or major depressive disorder. While this test does not confirm the presence of a mood disorder, it excludes alterations of the thyroid, which could alternatively explain the client's symptoms. Choices B, C, and D are incorrect. A CMP would not necessarily explain mood symptoms. Most certainly, electrolyte alterations may influence mood, but not to the extent of an actual disorder as it would be transient. An HbA1c would be useful to determine if the client has diabetes mellitus as well as how they are managing their glucose levels. CRP would be an inflammatory marker and is not specific to a psychiatric disorder. Additional Info TSH levels would help exclude thyroid disorders that may explain bipolar symptoms. Hypothyroidism may cause an individual to experience depressive mood symptoms, whereas hyperthyroidism may induce agitation, restlessness, irritability, and emotional lability. Last Updated - 27, Apr 2022

Which statement about behavior management is accurate? A. Negative feedback is not ethically appropriate when the client exhibits poor behavior. B. Skinner's theory scientifically supports behavior management techniques and procedures. C. Orem's theory scientifically supports behavior management techniques and procedures. D. Negative feedback is contraindicated because it is not scientifically sound and beneficial. Submit Answer

Explanation Choice B is correct. According to Skinner's theory, changes in behavior result from an individual's response(s) to the specific events, or stimuli, which occur in their respective environment. According to Skinner's research, everything we do and are shaped by our experience of punishment and reward. More specifically, when a stimulus-response pattern is rewarded, the individual is conditioned to respond similarly in the future. The key to Skinner's theory is reinforcement, or, more specifically, anything that strengthens the desired response. The central tenet of Skinner's work is that positively reinforced behavior will reoccur. When an individual is rewarded for a specific behavior, that individual is more likely to repeat the behavior due to positive reinforcement. Conversely, under Skinner's theory, negative reinforcement involves removing an undesirable stimulus to increase a behavior (not to be confused with a "negative punishment," where one would remove a pleasant stimulus to decrease a behavior). Despite Skinner's operant conditioning findings dating back to publications from the 1960s, many of these scientific theories continue to be implemented today. While Skinner's research and findings greatly influence countless fields, education is one of the most notable. Education appears to have been affected by Skinner's theories at all educational levels, having been integrated into all aspects of classroom management by instructors, instructional designers, administrators, etc., continuing to this day. Skinner's theories relating to behavior management techniques and procedures continue to be cited and implemented today. Choice A is incorrect. Research has shown that negative feedback is often a valuable form of feedback, as it allows an individual (or client) the opportunity to scrutinize their position, role, or behavior while concurrently alerting the client to a significant change(s) that is often needed. Based on the minimal information provided within this answer selection, nothing within Choice A indicates a breach of ethics has occurred. Choice C is incorrect. According to Orem's nursing theory, self-care consists of activities in which clients engage to maintain, restore, or improve health. The fundamental philosophy of Orem's theory is that in addition to all clients wanting to care for themselves, clients are able to improve more quickly and thoroughly by performing their own care as much as possible. Orem's nursing theory is not associated with behavior management. Choice D is incorrect. Research has shown that negative feedback is often a valuable form of feedback, as it allows an individual (or client) the opportunity to scrutinize their position, role, or behavior while concurrently alerting the client to a significant change(s) that is often needed. Learning Objective Recognize B. F. Skinner as the only theorist listed who made contributions toward the field of behavioral management and whose answer selection is accurate. Additional Info Various examples of positive reinforcement include verbal praise, a high test score, a monetary reward, a feeling of accomplishment, a gift card, etc. Car manufacturers use the principle of negative reinforcement in seatbelt safety systems: Once an individual enters a vehicle, a nonstop beeping or chiming will begin and continues until the seatbelt is fastened. This aggravating sound only stops once the passenger has exhibited the desired behavior, therefore increasing the likelihood that the seatbelt will be utilized in the future. One of the more common examples of negative punishment (i.e., the removal of a pleasant stimulus to decrease a behavior) is a child's time-out. This time-out period serves as a momentary removal of the children's access to something they enjoy (i.e., free play time, a specific game, an art project, time with friends, etc.). Additional examples of negative punishments include removing a particular toy, canceling a scheduled outing, failing to receive a planned pay increase or bonus, etc. Under Skinner's theory, negative reinforcement and punishment are two very different concepts. Reinforcement, even when it is negative, always increases a behavior. Conversely, punishment always decreases a behavior. Skinner was ranked by the American Psychological Association as the 20th century's most eminent psychologist. Last Updated - 16, Dec 2022

A patient presents with dizziness upon standing, bilateral hand tremors, inability to sleep, irritability, sweating, and a heart rate of 95. From what substance is the patient most likely experiencing these withdrawal symptoms? A. Alprazolam B. Nicotine C. Adderall D. Cocaine Submit Answer

Explanation Choice A is correct. Alprazolam (Xanax) is a type of benzodiazepine. The patient is presenting with classic benzodiazepine drug withdrawal symptoms: anxiety, coarse hand/tongue/eyelid tremors, irritability, increased autonomic activity (tachycardia and sweating), orthostatic hypotension, and insomnia. Choice B is incorrect. Typical nicotine withdrawal symptoms include headache, nervousness, poor concentration, anger, hunger, and restlessness. Choice C is incorrect. Adderal is an amphetamine drug. Typical amphetamine withdrawal symptoms include dysphoric mood, fatigue, insomnia or hypersomnia, and psychomotor agitation. Choice D is incorrect. Typical withdrawal symptoms of cocaine are similar to amphetamine withdrawal symptoms: dysphoric mood, fatigue, insomnia or hypersomnia, and psychomotor agitation. NCSBN Client Need Topic: Psychological medications, Subtopic: Chemical and other dependencies/substance use disorder, high-risk behaviors, lifestyle choices Last Updated - 30, Jan 2022

The nurse is teaching a group of students about drug toxicity. The nurse is correct in stating which of the following? Select all that apply. A. "Naloxone is the treatment for opioid toxicity." B. "Magnesium is the treatment for lead toxicity." C. "N-acetylcysteine is the treatment for naproxen toxicity." D. "Calcium gluconate is the treatment for magnesium toxicity." E. "Flumazenil is the treatment for benzodiazepine toxicity." Submit Answer

Explanation Choices A, D, and E are correct. The antidote for opioid toxicity is naloxone which may be given IV, IM, Intranasal, or SubQ. Magnesium toxicity is treated with calcium gluconate. Flumazenil is indicated for benzodiazepine toxicity. Choices B and C are incorrect. High lead levels would be treated with succimer, which is indicated for heavy metals and lead. N-acetylcysteine is utilized in the treatment of acetaminophen toxicity - not naproxen which is an NSAID. Additional Info Source : Archer Review Last Updated - 23, Apr 2022

The nurse is counseling a client with opioid use disorder. Which of the following medications may be used to treat this disorder? Select all that apply. A. Selegiline B. Naltrexone C. Methadone D. Buprenorphine E. Bupropion Submit Answer

Explanation Choices B, C, and D are correct. Naltrexone, Methadone, and Buprenorphine are three agents approved for the management of opioid use disorder. These medications have various mechanisms of action. Naltrexone is an opioid receptor antagonist and may be administered as a single dose injection. Buprenorphine is a partial agonist and is available in preparations such as sublingual tablets or film. Methadone is a full agonist that may be used daily. It is dispensed in a supervised setting. Choices A and E are incorrect. Selegiline is a monoamine oxidase inhibitor and is used in depression and Parkinson's disease. Bupropion is indicated in the treatment of depressive disorders. This medication may be useful in the management of nicotine addiction. Additional Info Medications used in opioid use disorder are efficacious when combined with appropriate counseling. The nurse should advocate for appropriate treatment choices such as buprenorphine, methadone, or naltrexone. Caution must be taken with methadone and buprenorphine as these two medications may cause respiratory depression when combined with other CNS depressants. Last Updated - 09, Feb 2022