ATI Mental Health: Entire Question Bank

The nurse is talking with a patient who voices concerns about the incidence of schizophrenia in her family. The patient states that she is worried the condition will be inherited by her teenage daughter. What response by the nurse is most appropriate? A. "Unfortunately, schizophrenia does not run in families." B. "Although some familial factors exist, there is no exact known cause for schizophrenia." C. "Your daughter would show some evidence of the condition by this point in her life, so there is no real reason to worry." D. "As long as your home environment is warm and loving, she will be fine."

"Although some familial factors exist, there is no exact known cause for schizophrenia." *The exact cause of schizophrenia is unknown; however, current research favots the theory that there is a neurologic basis with a genetic component. As with most chronic conditions, an unfavorable social environment contriutes to a poor prognosis. Schizophrenia usually develops in late adolescence or the early twenties

A nurse is assisting with a support group for clients who are nearing discharge from an acute care mental health facility. During a group session, a client states, "I'm scared about being discharged." Which of the following responses should the nurse offer? A. "Maybe you are not ready to be discharged yet." B. "Are there others in the group who have similar feelings they would like to share?" C. "You ought to be happy that you're being discharged." D. "How many in the group feel this member is not yet ready to be discharged?"

"Are there others in the group who have similar feelings they would like to share?" *Some of the goals of a support group include providing improved interpersonal relationships, mutual support, and methods to decrease stress. By asking if others in the group have similar feelings, the nurse allows the client to hear that feelings regarding discharge are not unique; also, the client might receive support from group members who express similar feelings

The nurse is talking to an elderly patient who states, "Sometimes I wish that I would just fall asleep and never wake up again." What is the most therapeutic response? A. "Oh, don't say things like that, everyone would really miss you." B. "Are you thinking about committing suicide?" C. "Many people would agree that dying during sleep is the best way to go." D. "You seem a little sad today, is there anything I can do to help?"

"Are you thinking about committing suicide?"

A nurse is collecting data from a client who was in a motor-vehicle crash that killed her sibling. The client is shaking and asks, "What can I do now?" Which of the following questions is the nurse's priority? A. "Are you thinking about hurting yourself?" B. "Do you have someone who could come here to be with you?" C. "How will this situation affect your life?" D. "What qualities have helped you cope with a crisis in the past?"

"Are you thinking about hurting yourself?" *The client's statement and current emotional state indicate that the client's greatest risk for self-harm. Therefore, the priority for the nurse is to ask the client about the possibility of suicide or self harm

Which caregiver statement regarding donepezil (Aricept) indicates a need for further nursing teaching? A. "I should give this drug with food to minimize gastric distress." B. "Aricept is rarely used because it causes liver problems." C. "I must increase fiber and fluid in my loved one's diet." D. "Providing frequent sips of cool liquids is helpful."

"Aricept is rarely used because it causes liver problems." *Liver functions should be monitored while on Aricept, but the caregiver is probably referring to tacrine, which is rarely prescribed because of hepatotoxicity. (1, 3, 4) The other options are correct. Give Aricept with food, increase fiber and fluid in the diet, and provide frequent sips of cool fluid.

The patient with dementia presents to the clinic for a routine examination. The patient's daughter, who is her full-time caregiver, states to the nurse, "I just don't know how much longer I can go on caring for Mom full time. My kids feel neglected, my marriage is suffering, and I feel so run down." What is the best response by the nurse? A. "You must stay strong for your mother. You are all she has." B. "You should discuss the many medications available for treating and reversing dementia." C. "Your mother's dementia will improve once we correct the cause." D. "As your mother's condition continues to deteriorate, we should discuss alternative care resources."

"As your mother's condition continues to deteriorate, we should discuss alternative care resources." *Dementia is a progressive loss of cognitive function that has no cure or medication that reverses it. Delirium generally improves once the cause is corrected. The nurse should acknowledge that the patient will continue to deteriorate and inform the patient's daughter of available resources to lessen the burden of being the sole caregiver to a family member with dementia. Telling the patient's daughter to be strong is neither therapeutic nor helpful.

A husband indicates to his wife's nurse in the hospital that he is worried she has been drinking too much lately. What is the best response? A. "Oh my, I'm really sorry to hear that." B. "How is the drinking affecting her?" C. "You seem upset by this; tell me about your concerns." D. "How long do you think this has been happening?"

"You seem upset by this; tell me about your concerns."

Needs increasing amounts of substance to achieve desired effect A. Abuse B. Psychological dependence C. Addiction D. Tolerance E. Withdrawal

Tolerance

The patient who is taking an SSRI medication must be monitored for A. weight loss B. hypernatremia C. kidney dysfunction D. gastrointestinal bleeding

gastrointestinal bleeding

A client who has cognitive impairment tells the nurse, "I'm leaving now. I have to be home by 5:00 PM because dinner will be ready." Which of the following responses by the nurse demonstrates the use of validation therapy? A. "It it 5:30 PM now. You are in the hospital and we will bring you dinner soon." B. "Don't worry about dinner. Your father is bringing dinner here for you tonight." C. "At home, you had dinner at 5:00 PM. Was your father a good cook?" D. "Your father was born around the year 1920. Can you tell me what year it is now?"

"At home, you had dinner at 5:00 PM. Was your father a good cook?" *This response validates the client's feelings and redirects the conversation to another topic so that the client can talk about personal memories. Validation therapy does not attempt to orient the client to reality but instead recognizes the underlying feelings expressed by the client and then redirects the conversation

A nurse is teaching a client who has schizophrenia about involuntary commitment. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A. "My family cannot commit me because I am homeless." B. "Even when I'm calm, I'll be forced to take psychotropic medication." C. "At least 2 doctors must support the commitment application." D. "At least 2 doctors must support the commitment application."

"At least 2 doctors must support the commitment application." *Involuntary commitment is a court-ordered mandate requiring admission of a client to receive mental health services either at an outpatient mental health facility. At least 2 doctors or other mental health professionals must agree that the client should be involuntarily committed to ensure due process and avoid accidentally committing the client

A nurse is caring for a client who has depression. The client states, "I am too tired and depressed to attend group therapy today." Which of the following responses should the nurse make? A. "Attending group therapy, even if you're tired, is an important part of your treatment." B. "That's okay if you're too tired to attend group therapy today, but you will have to go tomorrow." C. "It is normal to feel tired when you're feeling depressed. The others in group therapy also feel this way." D. "I agree with your decision to wait for participation in group therapy until you begin to feel better."

"Attending group therapy, even if you're tired, is an important part of your treatment." *Through this therapeutic response, the nurse is giving the client information to make an informed decision. Group therapy benefits clients who have depression by promoting peer support and reducing social isolation

A nurse is reinforcing teaching with a client who has anxiety and a new prescription for buspirone. Which of the following pieces of information should the nurse include in the teaching? A. "Buspirone carries a high potential for abuse." B. "Avoid consuming grapefruit juice when taking this medication." C. "Take the medication 4 times daily." D. "The peak effects of buspirone occur within 1 week."

"Avoid consuming grapefruit juice when taking this medication." *The nurse should instruct the client to avoid drinking grapefruit juice when taking buspirone because it can cause levels of the medication to increase. Elevated levels can cause drowsiness and subjective effects such as dysphoria

A nurse is caring for a client who has schizophrenia. Which of the following client statements indicates clang associations? A. "I am the king, and everyone should bow to me." B. "I'm feeling schmoolizious today." C. "Option, contrary, moose, allergic." D. "Basketball in the hall very tall.

"Basketball in the hall very tall. *A client who speaks using clang associations is choosing words based on their sound rather than meaning

A nurse is reinforcing teaching withthe adoptive parent of a preschool-age child who has a new diagnosis of ADHD. Which of the following statements should the nurse make? A. "Behaviors associated with ADHD are present prior to age 3." B. "This disorder is characterized by argumentativeness." C. "Below-average intellectual functioning is associated with ADHD." D. "Because of this disorder, your child is at an increased risk for injury."

"Because of this disorder, your child is at an increased risk for injury." *Inattentive or impulsive behavior increases the risk for injury in a child who has ADHD *Behaviors associated with ADHD are present before the age of 12 *Argumentativeness is associated with oppositional defiant disorder rather than ADHD *Below-average intellectual functions is associated with intellectual development disorder rather than ADHD

A nurse is reinforcing teaching with a client who has a new prescription for buspirone to treat anxiety. Which of the following statements should the nurse include in the teaching? A. "Use buspirone with caution because it raises the risk of suicidal thoughts." B. "You can minimize adverse effects by taking buspirone with grapefruit juice." C. "Buspirone enhances the depressant effects of alcohol." D. "Buspirone causes nausea in some people."

"Buspirone causes nausea in some people." *Adverse effects of buspirone include nausea, dizziness, headaches, nervousness, sedation, lightheadedness, and excitement

A nurse is reinforcing teaching with a client about cannabis use disorder. Which of the following client statements indicates an understanding of the teaching? A. "Withdrawal of cannabis occurs 3 days after cessation." B. "There are no physical manifestation of withdrawal from cannabis." C. "Drug screens can detect cannabis for up to 8 weeks after use." D. "Cannabis use can produce effects resembling the effects of alcohol use."

"Cannabis use can produce effects resembling the effects of alcohol use." *The nurse should explain to the client that, when used moderately, cannabis produces effects resembling the effects of alcohol and other CNS depressants. By depressing higher brain centers, CNS depressants release lower centers from inhibitory influences

A nurse is reinforcing teaching with a client about stress-reduction techniques. Which of the following client statements indicates understanding of the information? A. "Cognitive reframing will helpe me change my irrational thoughts to something positive." B. "Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate." C. "Biofeedback causes my body to release endorphins so that I feel less stress and anxiety." D. "Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety."

"Cognitive reframing will helpe me change my irrational thoughts to something positive." *Cognitive reframing helps the client look at irrational cognitions (thoughts) in a more realistic light and to restructure those thoughts in a more positive way *Biofeedback, rather than progressive muscle training, uses a mechanical device to promote voluntary control over autonomic functions *Physical exercise, rather than biofeedback, causes a release of endorphins that lower anxiety and reduce stress *Priority restructuring, rather than mindfulness, teaches the client to prioritize differently to reduce the number of stressors

A nurse in a mental health clinic is working with a client whose partner recently started working overseas. The client states, "My youngest child is having difficulty coping with my partner's absence." Which of the following responses should the nurse offer? A. "You should administer punishment if your child acts out." B. "Continue to do the activities that your family did before your partner's absence." C. "You child should see a counselor if he doesn't adjust to your partner's absence within 2 weeks." D. "Give your child the opportunity to spend as much time alone as he needs"

"Continue to do the activities that your family did before your partner's absence." *The nurse should instruct the client to continue usually family activities from before the partner's absence and to encourage the child to resume his usual activities. Returning to familiar activities can help re-establish a sense of normalcy for the family

A nurse is assisting with the admission of a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client's caregiver, which of the following statements is the priority to report to the provider? A. "Current medical conditions include diabetes that is controlled by diet." B. "Recent medications include a course of prednisone for acute bronchitis." C. "Current vaccinations include a flu vaccine last month." D. "Current medications include furosemide for congestive heart failure."

"Current medications include furosemide for congestive heart failure." *Diuretics (furosemide) are contraindicated for use with lithium due to the risk of toxicity. This is the greatest risk for the client and is therefore the highest priority to report to the provider

A nurse is providing support for a client who is grieving the loss of her mother who died from Alzeimer's disease. Which of the following statements should the nurse offer? A. "I know how you must be feeling. I recently lost my father." B. "Dealing with your mother's death must be difficult for you." C. "Knowing your mother is in a better place provides you with some comfort." D. "I want you to let me know what I can do to help you cope with your mother's death."

"Dealing with your mother's death must be difficult for you." *The nurse should use therapeutic communication when supporting a client who is grieving. This statement keeps the focus of the conversation on the client by acknowledging her grief and encourages further communication."

A nurse is reinforcing teaching with a family member of a client who has dementia. Which of the following statements should the nurse include? A. "Dementia is often associated with a reaction to a new medication." B. "Dementia is usually reversible with prompt treatment." C. "Dementia develops rapidly over a matter of hours or days." D. "Dementia is commonly associated with Alzheimer's disease."

"Dementia is commonly associated with Alzheimer's disease." *The nurse should identify the common causes of dementia, which include Alzheimer's disease, chronic alcohol use disorder, diseases affecting the neurological and vascular systems, and head trauma

A nurse on a rehabilitation unit is reinforcing teaching with the partner of a client who is experiencing stimulant withdrawal. Which of the following statements by the partner indicates an understanding of the teaching? A. "Increased energy is a sign of withdrawal." B. "Depression is a manifestation of withdrawal." C. "Decreased appetite is a manifestation of withdrawal." D. "Delirium tremens can occur during withdrawal."

"Depression is a manifestation of withdrawal." *The nurse should explain to the partner that depression and suicidal thoughts are the most serious adverse effects of stimulant withdrawal

A nurse is assessing a client who has a new diagnosis of major depressive disorder. Which of the following questions is the priority for the nurse to ask? A. "How would you describe your mood?" B. "How are you sleeping?" C. "Do you drink alcohol or use other substances?" D. "Do you ever think about suicide?"

"Do you ever think about suicide?" *The diagnosis of major depressive disorder indicates that the greatest risk for this client is suicide. Therefore, the priority for the nurse to ask is about suicidal ideation. Research shows that clients who have depressive disorders are at high risk for suicide due to the common presence of recurring thoughts of death

A nurse is participating with a disaster-support team following a tornado. When collecting data from a client who was affected by the tornado, which of the following questions should the nurse ask the client first? A. "Do you feel safe now that the tornado is gone?" B. "What do you think about the tornado?" C. "Do you have anyone you can contact for support?" D. "How do you usually cope with difficult situations?"

"Do you feel safe now that the tornado is gone?" *When using Maslow's hierarchy of needs, the nurse's priority is to determine if the client has a sense of safety

A nurse is reinforcing teaching with the family of a client who has Alzheimer's disease about donepezil. Which of the following statements should the nurse include? A. "Donepezil can improve cognitive functioning during the earlier stages of the disease." B. "Donepezil cures the disease process if it is started upon first recognition of dementia." C. "Donepezil provides long-term reversal of memory loss in the last phase of the disease." D. "Donepezil accelerates the breakdown of acetylcholine within the client's brain."

"Donepezil can improve cognitive functioning during the earlier stages of the disease." *The nurse should inform the client's family that donepezil is used to treat the manifestations of mild to severe Alzheimer's disease. Although donepezil does not prevent the progression of Alzheimer's disease, it is intended to prolong the client's ability to function in the early stages of the disease

A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for lorazepam. Which of the following statements should the nurse include? A. "Taking an antacid with the medication will decrease stomach upset." B. "Expect the medication to cause insomnia for the first 1 to 2 weeks." C. "Drinking caffeinated beverages will decrease the effectiveness of the medication." D. "Increase the dosage if the effectiveness of the medication decreases."

"Drinking caffeinated beverages will decrease the effectiveness of the medication." *The nurse should inform the client that consuming caffeine while taking benzodiazepines such as lorazepam will result in decreased effectiveness of the medication. Caffeine is a stimulant, and lorazepam is a CNS depressant; therefore, the substances will counteract each other. The client should avoid consumption of caffeine while taking this medication

A nurse is reinforcing teaching with a client who has an anxiety disorder about nonpharmacological ways to promote good sleep habits. Which of the following recommendations should the nurse make? A. "Schedule 20 minutes of aerobic exercise during the hour before bedtime." B. "Eliminate all caffeinated beverages from your diet." C. "Sleep for extra time when you can." D. "Eat a light snack containing carbohydrates before bedtime."

"Eat a light snack containing carbohydrates before bedtime." *A light snack consisting of a carbohydrate-based food or milk can help promote sleep when ingested before bedtime. Consuming heavy meals just before sleeping can promote insomnia

A nurse is discussing family therapy with a client. Which of the following statements by the nurse is therapeutic? A. "Family therapy helped my family." B. "I need to sign you up for family therapy." C. "Family therapy can bring about change." D. "Why do you think you need family therapy?"

"Family therapy can bring about change." *The nurse is using the therapeutic communication technique of providing information. By explaining what family therapy can offer, the nurse can empower the client to make a better decision about whether to pursue such therapy

A nurse is reinforcing teaching with a client who has anxiety and a new prescription for diazepam. Which of the following statements should the nurse make? A. "Feelings of sedation should resolve in about 1 week." B. "There is no risk of physical dependence with this medication." C. "You can decrease the dose when you feel especially anxious." D. "It will take several months for you to feel the maximum benefit maximum benefit of the medication."

"Feelings of sedation should resolve in about 1 week." *Adverse effects of diazepam and other benzodiazepines are sedation and psychomotor slowing. The nurse should inform the client that these effects should subside in 7 to 10 days."

A client recently diagnosed with terminal cancer states to the nurse, "I wish I were dead. I have no reason to live." Which of the following responses should the nurse offer? A. "You still have a lot to live for." B. "Please don't talk about that." C. "Your prescribed medication will make you feel better." D. "Have you been thinking of hurting yourself."

"Have you been thinking of hurting yourself." *The nurse's response focuses on the client's underlying feelings and begins to examine the obvious verbal clues of suicidal thoughts. Asking the client about suicidal thoughts is an important intervention by the nurse because if the client is contemplating suicide, the client should be able to discuss these feelings with the nurse

A nurse in a clinic is collecting data from a client who asks for help with depression. Which of the following questions is the nurse's priority? A. "Is there anything in particular that makes you feel angry?" B. "Have you had difficulty falling asleep or staying asleep?" C. "Have you thought about harming yourself in any way?" D. "Do you have someone you can talk with at home?"

"Have you thought about harming yourself in any way?" *The greatest risk to this client is an injury from self-harm; therefore, the nurse's priority is to determine whether the client is at risk by asking about thoughts of self-harm or a suicide plan

A nurse is collecting data from a client who has major depressive disorder. Which of the following questions is the priority for the nurse to ask the client? A. "Do you have any close friends?" B. "Can you describe how you feel about what's happening?" C. "Have you thought about hurting yourself?" D. "How are you dealing with being away from your family?"

"Have you thought about hurting yourself?" *The greatest risk to the client at this time is suicide. Therefore, the priority question the nurse should ask is if the client has any intent to self-harm

A nurse is reinforcing teaching with the partner of a client who has alcohol use disorder. Which of the following statements by the partner indicates an understanding of the teaching? A. "Having 6 beers in 2 hours is considered too much." B. "My partner is not at risk for cancer due to alcohol consumption." C. "My partner should consume no more than 20 drinks of alcohol in a week." D. "There is no genetic risk with abuse alcohol."

"Having 6 beers in 2 hours is considered too much." *Binge drinking refers to drinking too much alcohol in a short amount of time, causing the blood alcohol level to rise. This usually occurs with 5 or more drinks for males and 4 or more drinks for females within 2 hours

A nurse is reinforcing teaching with a family member of a client who has newly diagnosed with nyctophobia. Which of the following statements by the family member shows an understanding of the teaching? A. "He becomes anxious during electrical storms." B. "He avoids parties because he is afraid of meeting strangers." C. "He quit his job because he was afraid of entering the storage room." D. "He is unable to sleep without a light on."

"He is unable to sleep without a light on." *Clients who have nyctophobia are afraid of the dark. This phobia occurs often in children but can also occur in adults

A nurse is talking with an adolescent client who has major depressive disorder. The client tells the nurse into a situation in which he feels a friend betrayed him. Which of the following responses should the nurse offer? A. "Why should you feel betrayed by this friend?" B. "You'll get over this friend in time." C. "How does this situation make you feel?" D. "Jealousy will not help your friendship."

"How does this situation make you feel?" *This response by the nurse explores the client's feelings and encourages the expression of further ideas by the client

A nurse is assisting with the admission of a client who has alcohol use disorder. Which of the following statements indicates that the client is using denial as a coping mechanism? A. "I put in extra hours at work so I won't think about drinking." B. "I know that wine is good for my heart, so that's why I drink some each evening." C. "I make up for my drinking by taking my partner on nice vacations." D. "I am able to go to work every day, so I don't have a problem."

"I am able to go to work every day, so I don't have a problem." *Insisting that drinking is not a problem because the client can go to work every day indicates the defense mechanism of denial. This allows the client to ignore the existence of an alcohol use disorder

A nurse is reinforcing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by te client indicates understanding of the teaching? A. "I can expect my problems with PMDD to be worst with I'm menstruating." B. "I should avoid exercising when I am feeling depressed." C. "I am aware that my PMDD causes me to have rapid mood swings." D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."

"I am aware that my PMDD causes me to have rapid mood swings." *A clinical finding of PMDD is emotional liability. The client can experience rapid changes in mood *Clinical findings of PMDD are present furing the luteal phase of the menstrual cycle just prior to menses. *Aerobic and other exercise are effective treatments for depressive disorders, including PMDD *PMDD increases the client's risk for weight gain due to overeating. It is not appropriate to increase caloric intake

A nurse is caring for a client who has social anxiety disorder. Which of the following client statements should the nurse expect? A. "I am embarrassed to eat in public." B. "I often feel like I am going to have a heart attack." C. "I struggle to control my constant worry." D. "I have to step over the cracks in the sidewalk or else something bad might happen."

"I am embarrassed to eat in public." *The nurse should recognize that this statement describes social disorder. Clients who have this disorder experience severe anxiety or fear of behaving in a manner that can be negatively viewed by others. These clients attempt to avoid activities such as eating or speaking in public. If they are unable to avoid activities that trigger the anxiety, clients experience severe anxiety and emotional distress

A nurse is assisting with the care of a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following reponses should the nurse make? A. "Why do you think you feel the need to give money away." B. "I am here to provide care and cannot accept this from you." C. "I can request that your case manager discuss appropriate charity options with you." D. "You should know that giving away your money us inappropriate."

"I am here to provide care and cannot accept this from you." *This statement is matter-of-fact and concise and is a therapeutic reponse to a client who has bipolar disorder *Asking a "why" question is a nontherapeutic form of communication and can promote a defensive client response *(C) This statement does not recognize the possibility of poor judgment, which is associated with nbipolar disorder. *(D) This statement offers disapproval and can be interpreted by the client as aggressive, which can promote a defensive client response

A nurse is teaching a client who has bipolar disorder and a new prescription for lithium. The nurse should identify that which of the following statements by the client indicates an understand of the teaching? A. "I should take my lithium on an empty stomach." B. "I can take ibuprofen for headaches while taking lithium." C. "I need to limit my salt intake while taking lithium." D. "I am likely to gain weight while taking lithium."

"I am likely to gain weight while taking lithium." *The nurse should instruct the client about eating a low-calorie diet while taking lithium because this medication can cause weight gain

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? A. "I am a superhero and am immortal." B. "I am no one, and everyone is me." C. "I feel monsters pinching me all over." D. "I know that you are stealing my thoughts."

"I am no one, and everyone is me." *This comment indicates the client is experiencing a loss of identity or depersonalization *(A) This comment indicates the client is experiencing delusions of grandeur *(C) This comment indicates the client is experiencing a tactile hallucination *(D) This comment indicates the client is experiencing thought withdrawal

The caregiver of a patient with dementia tells you, "I just can't do this anumore. I am physically and emotionally exhausted." What is the appropriate intial response? A "Have you considered use of respite care?" B. "I am so sorry that you are experiencing this." C. "Do you have other family members who can help?" D. "Community resources are available that may be helpful."

"I am so sorry that you are experiencing this." *Acknowledging the feelings of the caregiver and the stress they are experiencing is important in supporting them. (1, 3, 4) The other options are all things to explore to help with the burden but validating the caregiver's feelings is most important at this time.

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates that the client is displaying cognitive symptoms? A. "I just feel so hopeless." B. "The government has been watching my house." C. "I am unable to remember to brush my teeth." D. "I no longer enjoy the activities I used to love."

"I am unable to remember to brush my teeth." *The nurse should recognize that memory impairment is a cognitive symptom of schizophrenia. Other cognitive symptoms include impaired concentration, judgment, and problem-solving

A nurse in a long-term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following statements should the nurse make? A. "You have forgotten that this is your home." B. "You cannot go outside without a staff member." C. "Why would you want to leave? Aren't you happy with your care?" D. "I am your nurse. Let's walk together to your room."

"I am your nurse. Let's walk together to your room." *It is inappropriate to introduce oneself with each new interaction and to promote reality in a calm, reassuring manner *Avoid statements that can be interpreted as argumentative or demeaning *Use positive, rather than negative, statements *Using a "why" question can promote a defensive reaction and does not reinforce reality

What is your therapeutic response to a patient who states, "The food service workers put poisoin in my food, and there is a bomb in the bathroom."? A. "Who do you think is doing all these things? B. "Let's go together and check the bathroom." C. "Tell me how you believe these things are happening." D. "I believe that the hospital is a safe place."

"I believe that the hospital is a safe place." *Stating reality and emphasizing safety and security are the best response. (1, 2) The nurse should not validate or give credence to the delusion. (3) The patient is not able to state why they believe what they do, and asking only provides a forum for the patient to expand on their delusional thoughts.

A nurse is talking with the partner of a client who has alcohol use disorder. Which of the following statements by the client's partner should the nurse identify as an indication of codependence? A. "My partner is addicted to both alcohol and cocaine." B. "I have an alcohol problem just like my partner does." C. "My partner only drinks to deal with her major depression." D. "I call my partner's boss when she's had too much to drink to go to work."

"I call my partner's boss when she's had too much to drink to go to work." *The nurse should identify this statement as an indication of codependency in which the codependent individual takes on extra responsibilities and assists the client who has the alcohol use disorder in meeting obligations. This caregiving affects the individual's perception of self-worth and can cause the individual to put the needs of the client first

A nurse is reinforcing with the guardian of a school-aged child who has ADHD and a new prescription for clonidine. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I will not allow my child to eat anything within 2 hours of taking the medication." B. "I can expect my child to be drowsy while taking this medication." C. "I will give my child a dose of the medication at noon every day." D. "I will cut the tablet in half before giving it to my child."

"I can expect my child to be drowsy while taking this medication." *The nurse should instruct the guardian that clonidine can cause adverse effects like somnolence, fatigue, and hypotension

A nurse is determining a client's understanding of a new prescription of a new prescription for clonidine for the treatment of opioid use disorder. Which of the following statements by the client indicates an understanding of the instruction? A. "Taking this medication will reduce my craving for heroin." B. "While taking this medication, I should keep a pack of sugarless gum." C. "I can expect some diarrhea from taking this medication." D. "Each dose of this medication should be placed under my tongue to dissolve."

"I can expect some diarrhea from taking this medication." *Clonidine commonly causes clients to experience dry mouth, Chewing sugarless gum is an effective method to address this adverse effect *Clonidine is useful during opioid withdrawal. However, it does not reduce cravings *Clonidine reduces, rather than causes, diarrhea and other withdrawal manifestations related to autonomic hyperactivity *Buprenorphine, rather than clonidine, is administered sublingually

A nurse on a mental health unit is observing a client who has schizophrenia. Which of the following client statements should the nurse recognize as clang association? A. "Her mannerologies are poor." B. "My dog blank a boa to supreme heights." C. "I can play the flute while wearing a suit. You are cute." D. "My joints ache. My friend is in the joint."

"I can play the flute while wearing a suit. You are cute." *The nurse should recognize that this statement is an example of clang association. Clang association refers to the use of words that are based on sound rather than meaning. A client who has schizophrenia will often use words that rhyme or have a similar beginning sound

A nurse is reinforcing teaching with a client who has ADHD and a new prescription for a transdermal methylphenidate patch. Which of the following statements by the client indicates an understanding of the teaching? A. "I will rotate placing the patch on different parts of my upper body." B. "I can take showers with the patch in place." C. "If the patch bothers my skin, I will switch to the oral form of the medication." D. "I will apply a patch each night at bedtime."

"I can take showers with the patch in place." *The nurse should instruct the client that transdermal methylphenidate patches can be worn during bathing, showering, and swimming.

A nurse in a mental health clinic is caring for a client who is grieving over the sudden death of his child. Which of the following statements should the nurse offer? A. "Be grateful for the time you had with your child." B. "I know you are glad your child didn't suffer." C. "You are young and can have more children." D. "I cannot imagine how you are feeling right now."

"I cannot imagine how you are feeling right now." *The nurse should allow the client to express his feelings and talk about emotions without telling the client how to feel or diminishing the client's grief. This therapeutic response by the nurse by the nurse allows the client to express grief while providing the opportunity for further communication

A nurse is collecting data from a client who has major depressive disorder regarding suicide risk factors and protective factors. Which of the following client statements should the nurse identify as a protective factor that decreases the client's risk for suicide? A. "I am a college graduate and make a lot of money at my profession." B. "I consider myself a good problem solver." C. "My family lives out-of-state, and I spend my spare time at home." D. "I enjoy restoring antique weapons and have a nice collection."

"I consider myself a good problem solver." *The ability to problem-solve and to think critically is a protective factor against suicide. Feelings of low self-esteem or hopelessness are risk factors for suicide.

A nurse is collecting data from a client who has adjustment disorder. Which of the following statements by the client should the nurse recognize as a manifestation of this disorder? A. "I am unable to remember my address." B. "I feel like I am living in a fog." C. "I sometimes cannot remember large blocks of time." D. "I could have done something to prevent my cousin's death."

"I could have done something to prevent my cousin's death." *The nurse should recognize that this statement indicates adjustment disorder, which occurs as a response to a stressful event. Manifestations can include guilt, depression, anxiety, and anger. These feelings might accompany physical manifestation, social withdrawal, or work or academic changes. The disorder can be treated with antidepressant medications

Which patient statement indicates a positive step in the recovery from alcohol use disorder? A. "I do think my job is at the root of my alcohol consumption." B. "I don't have any power over the effects alcohol has on me." C. "I don't ever want to use alcohol again." D. "To stay sober I will increase my exercise and eat healthy foods."

"I don't ever want to use alcohol again." *Recognition of the need to not use alcohol is a positive step in the recovery from alcohol dependence. (1, 2) Blaming the stress of a job for alcohol consumption or stating, "I don't have any power over the effects alcohol has on me" is rationalization. (4) Increasing exercise and eating healthily is a good plan but does not in itself help the patient stay sober.

A patient with schizophrenia comes to the nurse and says, "Here we go, got flacks and sacks and jibbogny tomorrow. Would you like some?" What is the best response? A. "Say that again. I couldn't understand what you are saying." B. "Sure thing, flacks and sacks and jibbogny sound great to me." C. "I don't quite understand, but I do appreciate you including me." D. "You are not making any sense. Try to speak clearly."

"I don't quite understand, but I do appreciate you including me."

A nurse is interacting with a client who has a psychotic disorder when the client suddenly turns her head as if listening to something and says, "The boss says she is going to hit me with a stick!" Which of the following responses should the nurse offer? A. "The boss can't hurt you with that stick B. "Why are you talking to yourself?" C. "I don't see anyone, but it sounds like you are frightened." D. "There isn't anyone here but you and me, so you need to explain."

"I don't see anyone, but it sounds like you are frightened." *The nurse should respond by offering personal perceptions of the client's experience and should address the client's underlying emotions about the hallucination

A nurse in a mental health clinic is collecting data from a client who recently lost her partner after an extended illness. Which of the following statements by the client indicates that she might be experiencing major depressive disorder as opposed to typical grief? A. "I still sometimes get angry over this happening to my partner." B. "I feel no pleasure without my partner in my life." C. "I see reminders of my partner every day." D. "I feel like I should have done more to take care of my partner."

"I feel no pleasure without my partner in my life." *The inability to experience pleasure (anhedonia) is a manifestation of depressive disorder. In a typical grief reaction, the survivor may be sad and have feelings of emptiness but is still able to experience moments of pleasure

A nurse is collecting data from a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief? A. "I wish I had been nicer and more generous to my wife before she died." B. "I told my wife to go to the doctor, but she wouldn't listen to me." C. "I think about my wife all the time when I go on outings with my family." D. "I feel so empty without my wife that it's hard to get up every morning."

"I feel so empty without my wife that it's hard to get up every morning." *The nurse should identify that a client who has difficulty performing normal activities following the loss of a partner is at risk for complicated grief

A nurse is collecting data from a client who has schizophrenia. Which of the following statements by the client should the nurse recognize as an erotomaniac delusion? A. "My coworker is trying to poison me because he is afraid I'll take his job." B. "I have only met Jenny twice, but I know she'll love me." C. "I am selling my house before the earthquake hits in May." D. "The foil on my walls prevents the government from controlling me."

"I have only met Jenny twice, but I know she'll love me." *The nurse should recognize that a client who believes another person desires him or her romantically after meeting only a few times is demonstrating an erotomaniac delusion

A nurse is interacting with a client in a substance use disorder program. Which of the following statements indicates that the client is using intellectualization as a way of coping with the anxiety of admission? A. "I was just using the medication to help me out during a rough time in my life. I can stop whenever I want." B. "This all happened because my spouse is unemployed. That puts an enormous amount of stress on me." C. "I have read that problems with substances can have a variety of predisposing factors." D. "I just don't want to talk about it. Anyway, there is nothing you can do to help."

"I have read that problems with substances can have a variety of predisposing factors." *The nurse should identify this response as intellectualization, which is an attempt to use intellectual processes to avoid expressing the emotions that stem from stressful situations

A nurse is reinforcing teaching to a client who has a new prescription of amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? A. "I can expect to experience diarrhea while taking this medication. B. "I may feel drowsy for a few weeks after starting this medication." C. "I cannot eat my favorite pizza with pepperoni while taking this medication." D. "This medication will help me lose the weight that I have gained over the last year."

"I may feel drowsy for a few weeks after starting this medication." *Sedation is an adverse effect of amitriptyline during the first few weeks of therapy *Constipation rather than diarrhea can occur with TCAs, due to anticholinergic effects *Foods (pepperoni) should be avoided if the client is prescribed an MAOI rather than a TCA like amitriptyline *Observe for manifestations of hypomania or mania caused by CNS stimulation with phenelzine

A nurse is talking with a client who has anxiety disorder. The client states, "I have something important to tell you, but you have to promise to keep it a secret." Which of the following responses should the nurse make? A. "Anything you tell me is kept private between us." B. "I feel uncomfortable being asked to keep a secret for you." C. "Why do you feel that the information needs to be kept private?" D. "I might have to share the information with your provider."

"I might have to share the information with your provider." *The nurse should be honest with the client so that the client can decide whether to share the information. The information the client shares can be vital for the treatment plan and can present a safety risk for the client or others. Therefore, the nurse might be legally obligated to share the information with the client's provider and health care team

A nurse is reinforcing teaching with a client who has a new prescription for buspirone. Which of the following statements by the client indicates an understanding of the teaching A. "I need to watch for signs of dehydration." B. "I need to have my kidney function monitored while taking this medication." C. "I should take this medication on an empty stomach." D. "I might not notice the effects of this medication for several weeks."

"I might not notice the effects of this medication for several weeks." *The effects of buspirone develop slowly. The initial response takes at least a week, and a peak response takes several weeks. Because of the delayed action, buspirone should not be taken as a PRN medication for the relief of anxiety

A nurse is caring for several clients. Which of the following client statements should the nurse identify as expected for factitious disorder imposed on another? A. "I had to pretend I was injured in order to get disabiility benefits." B. "I know that my abdominal pain is caused by a malignant tumor." C. "I needed to make my child sick so that someone else would take care of them for a while." D. "I became deaf when I heard that my partner was having an affair with my best friend."

"I needed to make my child sick so that someone else would take care of them for a while." *A client who has factitious disorder imposed on another often consciously injures another person or causes them to be sick due to a personal need for attention or relief of responsibility *A client's falsification of an illness or injury for the purpose of personal gain is malingering *Although clients who have factitious disorder often use proper medical terminology, a client's fear of a serious illness is expected with illness anxiety disorder *Developing a sensoring impairment due to an acute stressor is an expected fiding of conversion disorder

A nurse is collecting data from a group of clients who have paraphilic disorders. Which of the following client statements should then nurse identify as an indication that a client has necrophilia? A. "I was arrested for making obscene phone calls." B. "I enjoy taking nitrous oxide prior to have an orgasm." C. "I like my partner to urinate on me during sex." D. "I often fantasize about having intercourse with a corpse."

"I often fantasize about having intercourse with a corpse." *A client who has a paraphilic disorder obtains sexual arousal or orgasm from stimuli or acts that are outside of societal norms. Fantasizing about having sex with a corpse is an expected behavior for a client who has an "other specified" paraphilic disorder of necrophilia. The presence of a paraphilic disorder does not necessarily mean the client will act on the thought or ideas

A nurse is interviewing a client who is seeking help for intimate partner violence. Which of the following client statements should the nurse identify as an indication that the client is in the tension-building phase of the cycle of violence? A. "Last night my partner beat me worse than ever before." B. "It'll be easier just to make my partner mad and get the violence over with." C. "I believe my partner is remorseful and won't hurt me again." D. "I only got shoved a little bit, and it was my fault for coming home late."

"I only got shoved a little bit, and it was my fault for coming home late." *This statement is an indicator of the tension-building phase of the cycle of violence. During this phase, episodes of violence are often minor, and the recipient might rationalize the episodes by accepting blame

A nurse is caring for a client who has excoriation disorder. Which of the following statements by the client should the nurse expect? A. "I pick my face when I am nervous." B. "I have bald patches from pulling out my hair." C. "I inspect my body in the mirror several times a day." D. "I am unable to part with any of my belongings."

"I pick my face when I am nervous." *The nurse should recognize that this statement is an indication of excoriation disorder. Clients who have excoriation disorder typically pick their faces when experiencing stress or anxiety

During the physical assessment, the nurse notices bruises and needle marks on the patient's antecubital space. What is the best therapeutic response? A. "What are these marks? Are you injecting IV drugs?" B. "I am going to ask the health care provider to look at your arms." C. "I see you have some bruises. Can you tell me what happened?" D. "Let me clean and bandage your arm to prevent infection."

"I see you have some bruises. Can you tell me what happened?"

A nurse is providing discharge teaching to the parent of an adolescent client who has bulimia nervosa and has been hospitalized for several weeks. Which of the following statements should the nurse identify as an indication that the parent understands the teaching? A. "I should allow my child to make independent decisions." B. "I should give my child a laxative every evening." C. "I should make sure my child takes an antipsychotic medication several times daily." D. "I should discourage my child from exercising."

"I should allow my child to make independent decisions." *Clients who have bulimia nervosa often demonstrate low self-esteem. The family should support the client emotionally and should encourage increasing independent decision making

A nurse is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the discussion A. "I can promote my client's sense of control by establishing a schedule." B. "I should encourage clients who have a schizoid personality disorder to increase socialization." C. "I should practice limit-setting to help prevent client manipulation." D. "I should implement assertiveness training with clients who have antisocial personality disorder."

"I should practice limit-setting to help prevent client manipulation." *When caring for a client who has a personality disorder, limit-setting is appropriate to help prevent client manipulation *Rather than establishing a schedule, ask for the client's input and offer realistic choices to promote the client's sense of control *Avoid trying to increase socializtion for a client who has a schizoid personality disorder *Implement assertiveness training for clients who have dependent and histrionic personality disorders

A nurse is reinforcing teaching about free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique? A. "I will write down my dreams as soon as I wake up." B. "I might begin to associate my therapist with important people in my life." C. "I can learn to express myself in a nonaggressive manner." D. "I should say the first thing that comes to my mind."

"I should say the first thing that comes to my mind." *Free association is the spontaneous, uncensored verbalization of whatever comes to a client's mind *Dream analaysis and interpretation are therapeutic tools, However, they are not an example of free association *Associating the therapist with significant persons in the client's life is an example of transference rather than free association *Learning to express feelings and solve problems in a nonaggressive manner is an example of assertiveness training, rather than free association

A nurse is leading a group therapy session for a group of clients. Which of the following client statements should indicate to the nurse that the client is using the defense mechanism of rationalization? A. "I became a team manager because I'm not tall enough to succeed at basketball." B. "I don't want to talk right now about the fire that destroyed my home." C. "I take amphetamines because it's the only way I can keep up with all the studying for my classes." D. "I will spend a day cleaning my house when I feel like my life is out of control."

"I take amphetamines because it's the only way I can keep up with all the studying for my classes." *Rationalization is the act of justifying unacceptable thoughts or behaviors with a seemingly acceptable explanation. Rationalization allows the client to protect the ego and avoid taking responsibility for actions or thoughts that can cause shame of embarrassment

A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse about fears of gaining weight. Which of the following responses should the nurse make? A. "Many clients are concerned about their weight. However, the dietitian will ensure that you don't get too many calories in your diet." B. "Instead of worrying about your weight, try to focus on other problems at this time." C. "I understand you have concerns about your weight, but first, let's talk about your recent accomplishments." D. "You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you."

"I understand you have concerns about your weight, but first, let's talk about your recent accomplishments." *This statement acknowledges the client's concern and then focuses the conversation on the client's accomplishments, which can promote client self-esteem and self-image *(A) This statement minimizes and generalizes the client's concern and is therefore a nontherapeutic reponse *(B) This statement minimizes the client's concern and is therefore a nontherapeutic response *(C) This statement minimizes the client's concern and is therefore a nontherapeutic reponse

A nurse is talking with the caregiver of a child who has demonstrated recent changes in behavior and mood. When the caregiver of the child asks the nurse for reassurance about their child's condition, which of the following responses should the nurse make? A. "I think your child is getting better. What have you noticed?" B. "I'm sure everything will be okay. It just takes time to heal." C. "I'm not sure what's wrong. Have you asked the doctor about your concerns." D. "I understand you're concerned. Let's discuss what concerns you specifically."

"I understand you're concerned. Let's discuss what concerns you specifically." *This therapeutic response reflects upon, and accepts, the caregovers' feelings, and it allows them to clarify what they are feeling *(A) This nontherapeutic response interjects the nurse's opinion and can cause the caregiver to withhold their thoughts and feelings *(B) This nontherapeutic response interjects the nurse's opinion and provides false reassurance which can cause the caregiver to withhold their thoughts and feelings *(C) This nontherapeutic response avoids addressing the caregiver's concerns directly and indicates disinterest by the nurse for wanting to discuss the concerns with the parents

A nurse in an acute care mental health facility is assisting with the evaluation of the plan of care for a client who has major depressive disorder and was admitted 1 week ago following a suicide attempt. Which of the following client statements should indicate to the nurse that the treatment plan has been effective? A. "I just don't want to talk about anything that has happened before my admission." B. "I was feeling completely hopeless when I tried to kill myself." C. "I am feeling really great today, and I think I am ready to go home." D. "I want to punch the doctors who put me in this hospital."

"I was feeling completely hopeless when I tried to kill myself." *This statement should indicate to the nurse that the client is meeting a short-term goal of being willing to discuss painful feelings that occurred at the time of the suicide attempt. The nurse should also evaluate whether the client is now willing to see help when feelings o self-harm occur

A nurse is reinforcing discharge teaching for a client who has schizophrenia and a new prescription for iloperidone. Which of the following client statements indicates understanding of the instructions? A. "I will be able to stop taking this medication as soon as I feel better." B. "If I feel drowsy during the day, I will stop taking this medication and call my provider." C. "I will be careful not to gain too much weight while taking this medication." D. "This medication is highly addictive and must be withdrawn slowly."

"I will be careful not to gain too much weight while taking this medication." *Antipsychotic medications (iloperidone) have a high risk of for significant weight gain. *Antipsychotic medications are considered a long-term treatment for schizophrenia. Discontinuing the medication can result in an exacerbation of manifestations *Drowsiness is a common adverse effect of antipsychotic medications. However, it is not appropriate to discontinue the medication *Antipyschotic medications are not considered addictive, and it is not necessary to titrate iloperidone when discontinuing treatment

A nurse is caring for a client who is to begin taking fluoxetine for treatment of panic disorder. Which of the following statements indicates the client understands the use of this medication? A. "I will take the medication at bedtime." B. "I will follow a low-sodium diet whike taking this medication." C. "I will need to discontinue this medication slowly." D. "I will be at risk for weight loss with long-term use of this medication."

"I will need to discontinue this medication slowly." *When discontinuing fluoxetine, the client should taper the medication slowly according to a prescribed tapered dosing schedule to reduce the risk of withdrawal symptoms *The client should take fluoxetine in the morning to minimize sleep disturbances *The client is at risk for hyponatremia while taking fluoxetine *The client is at risk for weight gain, rather than loss, with long-term use of fluoxetine

A nurse is reinforcing teaching to a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates uderstanding of the information provided? A. "It is common to treat depression with ECT before trying medications." B. "I can have my depression cured if I receive a series of ECT treatments." C. "I should receive ECT once a week for 6 weeks." D. "I will receive a muscle relaxant to protect me from injury during ECT."

"I will receive a muscle relaxant to protect me from injury during ECT." *A muscle relaxant (succinylcholine) is administered to reduce the risk for injury during induced seizure activity *ECT is indicated for clients who have major depressive disorder and who are not respnsive to pharmacological treatment *ECT does not cure depression. However, it can reduce the incidence and severity of relapse *The typical course of ECT treatment is 2 to 3 times a week for a total of 6 to 12 treatments

A charge nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the procedure? A. "TMS is indicated for clients who have schizophrenia spectrum disorders." B. "I will provide postanesthesia care following TMS." C. "TMS treatments usually last 5 to 10 minutes." D. "I will schedule the client for TMS treatments 3 to 5 times a week for the first several weeks."

"I will schedule the client for TMS treatments 3 to 5 times a week for the first several weeks." *TMS is commonly prescribed 3 to 5 times a week for the first 4 to 6 weeks *TMS is indicated for the treatment of major depressive disorder that is not responsive to pharmacological treatment. ECT is indicated for the treatment of schizophrenia spectrum disorders *Postanesthesia care is not necessary after TMS because the client does not receive anesthesia and is alert during the procedure *The TMS procedure lasts 30 to 40 min

A nurse is reinforcing teaching with a client who has acrophobia about the use of systemic desensitization as a method of behavioral therapy. Which of the following client statements indicates an understanding of the teaching? A. "I will snap a rubber band on my wrist when heights scare me." B. "I will slowly be exposed to places of increasing height." C. "I will need to stand on a very high place until I'm calm." D. "I will be asked to imitate how my therapist acts around heights."

"I will slowly be exposed to places of increasing height." *This statement indicates client understanding of systematic desensitization. This form of behavioral therapy gradually exposes the client to frightening places or situations and teaches the client to overcome the fear through the use of relaxation techniques

A nurse is reinforcing teaching with a client who has a new prescription for varenicline for smoking cessation. Which of the following statements by the client indicates an understanding of the teaching? A. "If I fail to stop smoking after 12 weeks, I will have to try another product." B. "I will take them medication for 7 days before I try to stop smoking." C. "This medication will cause me to lose weight as I stop smoking." D. "I will take the medication after eating a meal."

"I will take the medication after eating a meal." *The nurse should instruct the client that taking varenicline following a meal with a full glass of water will minimize the associated nausea

A nurse is talking with a client who has major depressive disorder. Which of the following client statements should the nurse identify as a covert statement of suicidal ideation? A. "I don't want to live any longer." B. "I think every day about killing myself." C. "My parents will be happier when I'm dead." D. "I won't have to deal with things much longer."

"I won't have to deal with things much longer." *The nurse should listen closely for overt and covert statements that can indicate a client's intent to commit suicide. Covert statements can indicate in an indirect way a client's plan for suicide or wish to no longer be alive. Covert statements are more difficult to identify because they do not openly express the client's suicidal thoughts like overt statements. The nurse should collect further data from the client's suicidal ideation and implement interventions to reduce the risk of a suicide attempt

A nurse is caring for a client who has end-stage lung cancer. Which of the following client statements should the nurse identify as an indication that the client is experiencing the bargaining stage of Kubler-Ross' stages of grief? A. "I would give anything to live to see my grandchildren born." B. "Can you make sure there hasn't been a mistake with my test results." C. "I feel so sad that I will be leaving my partner all alone." D. "What have I done to deserve this death sentence?"

"I would give anything to live to see my grandchildren born." *Kubler-Ross identified common responses of clients who experience any form of loss. These responses are divided into 5 stages. While each of these stages is experienced by clients, they are not necessarily experienced in a linear fashion or in the exact same order. Some clients can experience a stage more than once. This response shows that the client is in the bargaining stage and might be trying to make a deal with a higher power to prolong life

A nurse is assisting with the care of a client who has a terminal illness. The client yells at the nurse, "Get out of my sight. You've always bothering me about something!" Which of the following responses should the nurse offer? A. "You don't have to yell. I'm sorry you feel like I've bothered you." B. "I'll go, but I'll be back in a little while when you have calmed down." C. "I'm going to have to ask you to be quieter since there are other clients on this unit." D. "I'll be here if you would like to talk about how you feel."

"I'll be here if you would like to talk about how you feel." *This response by the nurse acknowledge the client's feelings and provides a mechanism for further conversation, which helps create and maintain a therapeutic relationship between the nurse and the client

A nurse is caring for a client who has a depressive disorder. The client states, "I'm no good, spend your time with someone else." Which of the following responses should the nurse provide? A. "Why do you put yourself down?" B. "Did you go to group therapy yesterday?" C. "You will feel better soon if you follow your treatment plan." D. "I'm going to stay with you for a while if you would like to talk."

"I'm going to stay with you for a while if you would like to talk." *This response is therapeutic because it shows the client that the nurse is interested in her feelings, which strengthens the nurse-client relationship

The nurse is talking to the patient's mother about enabling. Which statement by the mother indicates that additional intervention in needed for the enabling behavior? A. "I am going to let her take responsibility for her decisions." B. "I'm her mother. I'll always be there for her no matter what." C. "We have been denying the problem for a long time." D. "I will support her recovery by attending Al-Anon."

"I'm her mother. I'll always be there for her no matter what."

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements should the nurse expect from a client who has this type of personality disorder? A. "I'm scared that you're going to leave me." B. "I'll go to group therapy if you'll let me smoke." C. "I need to feel that everyone admires me." D. "I sometimes feel better if I cut myself."

"I'm scared that you're going to leave me." *Clients who have avoidant personality disorder often have a fear of abandonment. This type of statement is expected *(B) Thie statement indicates manipulation, which is expected from a client who has antisocial personality disorder *(C) This statement indicates a need for admiration, which is expected from a client who has narcissistic personality disorder *(D) This statement indicates a risk for self-injury, which is expected from a client who has borderline personality disorder

The paranoid schizophrenic patient states that his whole family has conspired to have him put in the hospital and that the medical staff are part of the conspiracy. Which is the nurse's most therapeutic response? A. "I promise that I want to help you." B. "You know your family is concerned about you." C. "I'm sorry you feel that way. I'll be around if you want to talk about your feelings." D. "The doctors are trying to help you feel better. The have your best interest in mind."

"I'm sorry you feel that way. I'll be around if you want to talk about your feelings." *Arguing with the paranoid patient, or defending self or others, reinforces the paranoia. Passively offering self to the patient to approach you rather than the other way around is helpful to the nurse-patient relationship

A nurse is having a conversation with a newly admitted client when the client suddenly stops talking. Which of the following statements should the nurse make? A. "Apparently, you no longer wish to talk with me. Have I done something to make you angry?" B. "I've noticed you have become quiet. Share with me what you are thinking when you are ready." C. "It is okay if you don't wish to talk anymore right now. We can meet again tomorrow." D. "You need to talk during this time I have set aside for you. Talking is what will get you out of here."

"I've noticed you have become quiet. Share with me what you are thinking when you are ready." *This statement by the nurse is therapeutic. Focusing on the quietness sometimes helps the client talk about thoughts and feelings

Which statement by the patient's family indicates the need for more teaching about the treatment of anorexia nervosa? A. "If she'll just eat more, we can take her home and she'll be okay." B. "She will have to hospitalized if she has dehydration or electrolyte imbalance." C. "Therapy could take between 1-6 years for this disorder." D. "Support groups and family therapy are important aspects of treatment."

"If she'll just eat more, we can take her home and she'll be okay."

A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements should the nurse make? A. "Limit daytime napping to an hour maximum." B. "Watch TV as you fall asleep." C. "If you aren't able to sleep, you can get out of bed and read a book." D. "Track the number of hours that you sleep each night."

"If you aren't able to sleep, you can get out of bed and read a book." *The nurse should instruct the client to get of bed and participate in a quiet activity such as reading until he feels sleepy, at which time he should return to bed.

A nurse is caring for a client who has schizophrenia and states, "My doctor is trying to kill me." Which of the following responses should the nurse make? A. "Why would you say that your doctor is trying to kill you?" B. "It must be frightening to feel that your doctor is trying to kill you." C. "You doctors wants to help you, not kill you." D. "How long has your doctor been trying to kill you."

"It must be frightening to feel that your doctor is trying to kill you." *When a client is experiencing a delusion, the nurse should empathize with the feelings behind the delusion.

You are caring for a patient with a personality disorder. Which statement made by you indicaes a need for additional education setting boundaries? A. "I can spend 20 minutes talking with you, and then I have to pass medications." B. "I understand that you are bored, but you have to complete the task." C. "If you promise not to cause trouble, I'll give you the magazine." D. "When someone is speaking in group, it is polite to listen while they speak."

"If you promise not to cause trouble, I'll give you the magazine." *If a privilege is granted and contingent on a future behavior, the patient and nurse are setting up future manipulation and power struggles. (1) The boundary and anticipated actions are very clear in this statement. (2) In this statement, the feelings are acknowledged, but the expectations remain clear. (4) Behavior and circumstances are clearly articulated.

A nurse is reinforcing teaching with the parents of a school-aged child who has attention deficit hyperactivity disorder (ADHD). Which of the following instructions should the nurse include? A. "Ignore your child's attention-seeking behaviors that are not dangerous." B. "Administer ADHD medications within 30 min of your child's bedtime." C. "Continue with an activity as planned even if your child becomes frustrated." D. "Expect your child to gain weight after starting ADHD medications."

"Ignore your child's attention-seeking behaviors that are not dangerous." *The nurse should instruct the parents about the use of planned ignoring. This technique ignores attention-seeking behaviors that are not dangerous to the child or others. If the child learns that the behavior will not elicit the desired response, then the behavior should decrease

A nurse is reinforcing teaching with a client who has a prescription for a tricyclic antidepressant. Which of the following instructions should the nurse share? A. "Take this medication within 1 hour of waking each morning." B. "Limit your alcohol intake to 2 drinks per week while taking this medication." C. "It can take 6 weeks to achieve the full therapeutic effect of this medication." D. "Stop taking the medication if you experience dizziness."

"It can take 6 weeks to achieve the full therapeutic effect of this medication." *The nurse should instruct the client that it can take 6 to 8 weeks to achieve the full therapeutic effectiveness of a tricyclic antidepressant

A nurse is caring for a client with obsessive-compulsive disorder (OCD) who has been taking fluoxetine for 3 months. The client states, "This medication isn't working. I want to stop taking it." Which of the following responses should the nurse make? A. "It is best to discontinue the medication slowly over 1 or 2 months." B. "If the medication hasn't helped you in 3 months, it's not going to." C. "You will likely gain weight if you stop taking the medication." D. "This medication is the only treatment for your condition."

"It is best to discontinue the medication slowly over 1 or 2 months." *The nurse should respond by telling the client that withdrawing from the medication should be done slowly to reduce any manifestations of withdrawal. This can be achieved by reducing the dosage by 25% every 1 to 2 months

A nurse is reinforcing teaching with the guardian of a female adolescent client who has bulimia nervosa. Which of the following statements by the guardian indicates an understanding of the teaching? A. "My daughter is at risk for developing high blood pressure." B. "It is important for my daughter to have regular dental checkups." C. "I should weigh my daughter daily for several weeks." D. "Bleeding during my daughter's periods will increase."

"It is important for my daughter to have regular dental checkups." *For a client who has bulimia nervosa, repeated vomiting erodes tooth enamel and predisposes the teeth to caries. Therefore, frequent checkups are essential.

The family of a patient being treated for a recent diagnosis of schizophrenia voices concerns to the nurse. They report the patient just told them that the pepper flakes on his potatoes were crawling bugs. What reponse by the nurse is most appropriate? A. "At this stage it is most important to humor him and agree that you see them as well." B. "To reduce his stress, just throw out the food." C. "It is important to tell him that you do not see the bugs." D. "The best thing to do in this case is to confront him and let him know that he is mistaken."

"It is important to tell him that you do not see the bugs." *The patient is experiencing an illusion. It is most important to offer support but to attempt to provide reality orientation. Confronting him may cause anger or increased anxiety and should be avoided

A nurse is caring for a client who has obsessive-compulsive disorder and feels that pacing the floor for a specific number of times is necessary or else "something bad will happen." Which of the following responses should the nurse provide? A. "Nothing terrible is going to happen to you. Please stop this behavior." B. "Are you seeking attention with this behavior?" C. "It may help if we talked about why you find it necessary to pace the floor." D. "Are you pacing to work off excess energy?"

"It may help if we talked about why you find it necessary to pace the floor." *This response is therapeutic and encourages the client to discuss the underlying thoughts and feelings that are causing anxiety

A nurse is caring for a client who attends family counseling with his partner and their children. The client tells the nurse that he isn't going to attend any further sessions and states, "I don't have time for all that talking." Which of the following responses should the nurse provide? A. "It must be difficult for you to talk about family problems." B. "You should continue attending the family counseling sessions until the therapist tells you to stop." C. "If you continue to go to family counseling, I'm sure you'll be able to resolve your family problems soon." D. "I think you need to continue family therapy if your partner and children want to receive further counseling."

"It must be difficult for you to talk about family problems." *The nurse's response indicates empathy for the client's feelings and is an example of the therapeutic communication technique of verbalizing what the client implied. With this technique, the nurse helps him focus on the actual reason for not wanting to continue family therapy

A nurse is talking with a client about his admission to a mental health unit. The client states, "I just don't know if I should be here. What will my family think?" Which of the following responses by the nurse uses the therapeutic communication technique of reflection? A. "It sounds like you are concerned about your family's reaction." B. "What your family thinks isn't important; you need to be concerned about getting well." C. "I suspect your family doesn't seem to understand you. D. "Many clients are concerned about the reaction of their families."

"It sounds like you are concerned about your family's reaction." *In a reflective response, the nurse directs feelings and statements back to the client, allowing the client to think about personal feelings

A nurse is discussing exercise activities with an acute care client who has schizophrenia and is overweight due to psychotropic medications. The client refuses to participate in an aerobic exercise class and instead requests to walk in the facility's gym. Which of the following responses should the nurse make? A. "Can you tell my why you do not want to participate in the planned group activity?" B. "Do you understand that psychotropic medications cause weight gain?" C. "The aerobics class will be more effective at burning calories than walking." D. "It sounds like you have come up with an alternative exercise that works for you."

"It sounds like you have come up with an alternative exercise that works for you." *The nurse is using therapeutic techniques of acceptance, giving recognition, and encouragement by supporting the client's idea of a way to exercise

A nurse at a long term care facility hears an assistive personnel (AP) talking with an older adult client who has dementia with periods of confusion. Which of the following statements indicates that the AP requires further instructions? A. "We will be serving breakfast in 10 min. I will stay here while you get ready." B. "It's Monday morning. I know that your favorite television shows are on this evening." C. "I see that you have a new photo on the wall. Can you tell me who that girl is?" D. "It's almost time for your appointment. Let me do your hair for you and brush your teeth."

"It's almost time for your appointment. Let me do your hair for you and brush your teeth." *When a client with dementia has periods of confusion, the AP should allow the client additional time to complete activities that can be performed independently. Insisting on completing the task for the client or attempting to hurry her can provoke agitation. The AP should encourage independence and provide assistance only if the client asks for or needs it

A nurse is caring for a client who has major depressive disorder. The client states, "I might as well be dead. I have always been a failure." Which of the following responses should the nurse make? A. "Why do you think you feel this way?" B. "You have a great deal to offer in life." C. "Let's discuss these feelings further." D. "Feelings like a failure is expected with depression."

"Let's discuss these feelings further." *The nurse is using the therapeutic technique of exploring the client's feelings. The client's comments indicate a risk for self-harm, and the nurse should further explore to confirm this

A nurse is caring for a client who has antisocial personality disorder. The client uses manipulation to gain access to a smoking area from which his access has been limited as a behavioral intervention. Which of the following statements should the nurse make? A. "You know you shouldn't use the smoking area." B. "You know that manipulation is not the right thing to do." C. "Let's review the consequences of your actions." D. "I can talk with the provider about reducing your smoking restriction."

"Let's review the consequences of your actions." *When communicating with a client who has antisocial personality disorder, the nurse should set clear and realistic limits on behavior that all staff members adhere to, identify the client's undesirable behavior, and communicate the consequences of that behavior

A nurse in an acute mental health facility is caring for a client who states, "This place is ridiculous. I can't stand spending another day here!" Which of the following responses should the nurse make? A. "You should focus on the good things so the bad things seem less important." B. "I'm sure tomorrow will be a better day." C. "You shouldn't be so negative when you are young and physically healthy." D. "Let's talk for a while about the events of your day."

"Let's talk for a while about the events of your day." *The nurse should use focusing as a therapeutic communication technique that encourages the client to talk about feelings.

A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing? A. "Life isn't worth living if I gain weight." B. "Don't pretend like you don't know how fat I am." C. "If I could be skinny, I know I'd be popular." D. "When I look in the mirror, I see myself as obese."

"Life isn't worth living if I gain weight." *This statement reflects the cognitive distortion of catastrophizing because the client's perception of their appearance or situation is much worse than their current condition *(B) This statement reflects the cognitive distortion of personalization rather than catastrophizing *(C) This statement reflects the cognitive distortion of overgeneralization rather than catastrophizing *(D) This statement reflects a perception of distorted body image commonly experienced by the client who has anorexia nervosa. However, it is not an example of catastrophizing

A nurse is teaching a client who has seasonal affective disorder (SAD) about the use of light therapy. Which of the following statements should the nurse make? A. "Light therapy suppresses the natural nighttime release of melatonin." B. "You should plan your light therapy session before going to bed." C. "You should begin with 2-minute light therapy sessions and gradually progress to 10-minute sessions." D. "Light therapy is less effective at treating SAD than antidepressant medications."

"Light therapy suppresses the natural nighttime release of melatonin." *Melatonin is produced nocturnally by the pineal gland; larger amounts are produced during months containing more hours of darkness. These large amounts of melatonin seem to cause SAD in clients who are susceptible to this disorder. Light therapy is thought to improve depression by suppressing melatonin production and increasing serotonin production

A nurse is reinforcing teaching with a client who wants to stop smoking by using nicotine lozenges. Which of the following statements should the nurse make? A. "Drink water directly before taking the lozenge." B. "Place the lozenge under your tongue and let it dissolve." C. "Limit your use to no more than 20 lozenges per day." D. "Take 2 4-mg lozenges right after waking up in the morning."

"Limit your use to no more than 20 lozenges per day." *The nurse should instruct the client that users should consume no more than 5 lozenges within 6 hours and should not have more than 20 lozenges per day

A nurse is talking with a client who is at risk for suicide following their partner's death. Which of the following statements should the nurse make? A. "You will feel much better with time. I promise." B. "Suicide is not the appropriate way to cope with loss." C. "Losing someone close to you must be very upsetting." D. "I know how difficult it is to lose someone close to you."

"Losing someone close to you must be very upsetting." *This statement is an empathetic response that attempts to understand the client's feelings *(A) This statement gives the client false reassurance and is therefore not therapeutic *(B) This statement implies judgment and is therefore not an empathetic or therapeutic reponse *(D) This statement focuses on the nurse's experiences rather than the client's and is therefore not therapeutic

The patient will be discharged within a day or two. Which statement by the patient's family indicates a need for further discussion about the diagnosis of schizophrenia? A. "A stable home environment will help to prevent relapse." B. "He might always hear voices, but the medications will help." C. "Medication will eliminate his blunted affect and social isolation." D. "If he fails to take his medication, it will probably lead to readmission."

"Medication will eliminate his blunted affect and social isolation."

A nurse is reinforcing teaching with the caregiver of a child who has pica. Which of the following statements should the nurse identify as an indication that the caregiver understands the teaching? A. "My child will have this disorder for the rest of his life. B. "My child will return undigested food to his mouth because of this disorder." C. "My child might try to eat dirt when we are at the playground." D. "My child will need to be repositioned during feedings."

"My child might try to eat dirt when we are at the playground." *Pica is the persistent eating of non-food substances that have no nutritional value such as dirt or paint

Which statement causes the nunrse to document a schizophrenic patient's delusion of persecution? A. "Did you know that I own this hospital and pay all these people to work for me?" B. "My doctor talked to all the other patients, but not to me. He doesn't want me to get well." C. "The president's speech tonight is going to give me a coded message." D. "I am going to wait in front of the hospital this morning for my limousine to pick me up and take me to my private jet."

"My doctor talked to all the other patients, but not to me. He doesn't want me to get well." *Delusions can be either gradiose or persecutory. An individual who beleives he owns the hospital or is planning to be picked up by a limousine or has a private jet is having delusions of grandeur. Individuals with delusion of persecution believe that they are being persecuted by agencies, by other people, or by supernatural beings. The patient who believes the president's speech is coded is having an idea of reference

An exhausted daughter is the sole caregiver to a patient with moderate Alzheimer disease (AD). She asks the nurse what respite care entails. Which statement indicates that the caregiver understands the nurse's response? A. "My mom would stay in a long-term care facility for a short time while I rest." B. "Home health aides would come to our home and help me with housework." C. "A registered nurse would provide total care for my mom in 3 day interval." D. "I would be connected with a special support group to share stresses and communicate with other caregivers."

"My mom would stay in a long-term care facility for a short time while I rest." *Respite care is placing the patient temporarily in a long-term care facility (usually for no longer than a month) to give the family respite from the responsibility of 24/7 care

A nurse is reinforcing teaching with the partner of a client who is at risk for alcohol withdrawal after 6 hours of cessation. Which of the following statements by the partner indicates an understanding of the teaching? A. "My partner might experience seizures after 3 days of abstinence." B. "Delirium tremens generally occurs within 24 hours." C. "Hypotension is a manifestation of alcohol withdrawal." D. "My partner might begin to shake."

"My partner might begin to shake." *Tremulousness is the classic sign of alcohol withdrawal, commonly called "the shakes" or jitters. Tremulousness begins 6 to 8 hours after alcohol cessation

A nurse is caring for a client who has anxiety disorder. Which of the following statements by the client should the nurse recognize as demonstrating the defense mechanism of displacement? A. "I smoked for years, but now I cannot stand to be around cigarette smoke." B. "I didn't get the promotion at work because my boss hates me." C. "My partner yelled at me, so I made the cat go outdoors." D. "I won't worry about losing my job until my child's break from school is over."

"My partner yelled at me, so I made the cat go outdoors." *This statement is consistent with the use of displacement. Displacement is the transference of emotions associated with a person, object, or situation to another non-threatening person, object, or situation.

A nurse in a long-term mental health facility is caring for a client who has a personality disorder. Because the client has broken a unit rule, phone privileges are being revoked. The client asks the nurse, "Can't I just make another phone call?" Which of the following responses should the nurse make? A. "No, you can't. Go sit in your room." B. "Okay, if you promise to obey the rules for the rest of the day." C. "No, you can't. You have broken the rules that apply to everyone." D. "You can make only a 5-minute phone call."

"No, you can't. You have broken the rules that apply to everyone." *The nurse's response correctly enforces unit rules, identifies the reason for the consequence, and decreases the likelihood of future manipulative behavior

The patient is taking olanzapine (Zyprexa) as prescribed. Which patient comment suggests that the medication is successively treating the patient's positive symptoms of schizophrenia? A. "I can leave the hospital whenever I want to." B. "Nurse, I am ready to go home. Would you call my mother?" C. "I can still hear the voices, but they are very distant." D. "The angel stopped talking; now she just sits and waves."

"Nurse, I am ready to go home. Would you call my mother?"

A nurse on an acute care mental health unit is collecting data from a client who was admitted following an opioid overdose. The client states that he wants his admission to remain confidential. Which of the following responses should the nurse make? A. "There is no way we can keep the details of your admission a secret from other people." B. "Being admitted as a confidential client will cost extra." C. "Only the staff involved in your care will know the details of your admission." D. "We will only release information about your admission to your family members."

"Only the staff involved in your care will know the details of your admission." *Keeping the details of a client's admission and care confidential is a legal requirement as as part of the nurse's ethical duty. The nurse should inform the client that only members of the staff who are involved in his care will have access to information about his admission and treatment

A nurse is caring for a client who has Alzheimer's disease. The client's adult son reports that the client has begun wandering away from home. Which of the following responses should the nurse make? A. "You should plan to move your mother into your home soon." B. "Place a complex lock at the top of each door that leads outside." C. "It is time to place your mother in a long-term care facility." D. "Have you reminded your mother about the dangers of wandering away from home?"

"Place a complex lock at the top of each door that leads outside." *The nurse should instruct the client's son to place complex locks at the top of doors that lead outside to prevent the client from wandering away from home. The nurse should also encourage the client's son to place a non-removable medical alert bracelet on the client with the client's name, address, and telephone number

A nurse is assisting a client who has major depressive disorder. The client states, "This has been the worst day of my life." Which of the following responses should the nurse make? A. "You should focus on positive things rather than negative things." B. "We all have a bad day from time to time." C. "Why would someone with so much to live for say that?" D. "Please take a seat and talk to me about it."

"Please take a seat and talk to me about it." *This response by the nurse is therapeutic and encourages the client to talk about his feelings and what might have caused them. This helps the nurse develop a trusting relationship with the client, in which the client will feel safe opening up to the nurse. Using therapeutic communication techniques helps to identify the client's specific needs and problems, which can lead to a solution

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of teaching? A. "Children older than 5 are at greater risk for abuse." B. "Substance use disorder does not increase the risk for violence." C. "Entering an intimate relationship increases the risk for violence." D. "Pregnancy increases the risk for violence from a spouse of partner."

"Pregnancy increases the risk for violence from a spouse of partner." *Pregancy tends to increase the likelihood of violence from a spouse or partner *Children younger than 4 years of age are at an increased risk for abuse *Substance use disorder increases the risk for violence *Vulnerable persons are an increased risl for violence when they try to leave the relationship

A nurse is caring for a client who is prescribed lithium therapy. The client tells the nurse of the plan to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make? A. "That is a good choice. Ibuprofen does not interact with lithium." B. "Regular aspirin would be a better choice than ibuprofen." C. "Lithium decreases the effectiveness of ibuprofen." D. "The ibuprofen will make your lithium fall too low."

"Regular aspirin would be a better choice than ibuprofen." *Aspirin is recommended as a mild analgesic rather than ibuprofen due to the risk of lithium toxicity. *Ibuprofen is not recommended for clients taking lithium. It does not decrease the effectiveness of ibuprofen but concurrent use is not recommended due to the risk of toxicity. It increases the risk for a toxic, rather than low, lithium level

A nurse is caring for a client who is confused and wanders at night. The nurse asks the charge nurse if the client can be placed in physical restraints at bedtime. Which of the following responses should the charge nurse provide? A. "Restraints can be used if the client is having verbal outbursts." B. "Restraints have been effective in reducing the number of client falls." C. "Restraints can used only when the unit manager approves." D. "Restraining the client can increase confusion."

"Restraining the client can increase confusion." *Restraining a confused client can worsen confusion. The nurse should use other methods to prevent wandering such as suggesting diversional activities, reducing stimulation, and administering a PRN medication

A nurse is reinforcing teaching with the family of a client who has schizophrenia. Which of the following statements by a family member indicates an understanding of the teaching? A. "We will not set time limits for discussing her delusions." B. "We will avoid reacting to her command hallucinations." C. "She might lose weight due to her medications." D. "She might be having a relapse if she stops attending social events."

"She might be having a relapse if she stops attending social events." *The family of a client who has schizophrenia should be taught the signs of relapse, including avoiding other people, sleep disturbances, difficulty concentrating, and being unable to tell reality from nonreality

A nurse is assisting with the care of a client who has generalized anxiety disorder and is experiencing severe anxiety. Which of the following statements actions should the nurse make? A. "Tell me about how you are feeling right now." B. "You should focus on the positive things in your life to decrease your anxiety." C. "Why do you believe you are experiencing this anxiety?" D. "Let's discuss the medications your provider is prescribing to decrease your anxiety."

"Tell me about how you are feeling right now." *Asking an open-ended question is therapeutic and assists the client in identifying anxiety *Offering advice is nontherapeutic and can hinder further communication *Asking the client a "why" questions is nontherapeutic and can promote a defensive client response *Postpone reinforcing health teaching until after acute anxiety subsides. Clients experiencing severe anxiety are unable to concentrate or learn

A nurse on a mental health unit is receiving reports about a group of clients. Which of the following client statements is an example of a persecutory delusion? A. "I am the mayor of this town." B. "My doctor is in love with me." C. "That other nurse is trying to poison me." D. "The end of the world is coming tonight."

"That other nurse is trying to poison me." *This statement is an example of a persecutory delusion in which the client believes that someone is trying to cause harm

A nurse is caring for a client who has bipolar disorder. The client states, "My family wants me to come home for a visit. What do you think I should do?" Which of the following responses should the nurse make? A. "Tell me how you are feeling about their request." B. "I think spending some time with your family is important." C. "Maybe you shouldn't go if you're not sure about the visit." D. "What does your social worker think you should do?"

"Tell me how you are feeling about their request." *This statement is an example of a therapeutic response because the nurse is inquiring how the client feels and using reflection to encourage independent thinking

A nurse is caring for a client who is dying. The client's son appears visibly upset when he visits. Which of the following statements should the nurse make to the client's son? A. "Tell me how you're feeling about your mother's illness." B. "Consider bringing a support person when you visit your mother." C. "It is okay to feel angry when losing someone close to you." D. "You should think about joining a grief support group."

"Tell me how you're feeling about your mother's illness." *The nurse is using a therapeutic communication technique of offering a general lead to allow the son to express his feelings. This statement indicates that the nurse is interested in not only the client but also the client's family

A nurse in a rehabilitation center for clients with substance use disorders is collecting data from a client who is being admitted. The client tells the nurse, "I am afraid of other people finding out that I am in a rehabilitation center." Which of the following responses should the nurse make? A. "You don't need to worry about that." B. "You should be proud of yourself for getting treatment." C. "Why do you care what other people think?" D. "Tell me more about how you are feeling about being here."

"Tell me more about how you are feeling about being here." *The nurse is using therapeutic communication by exploring the client's feelings and encouraging the client to discuss them.

A nurse is teaching with a client in the day room of an acute care mental health facility. The client accuses the nurse of being "too bossy" and states the nurse does not have the right to pressure anyone. Which of the following responses should the nurse provide? A. "What makes you say that?" B. "Tell me what I said that made you feel uncomfortable." C. "Why are you feeling pressured by me?" D. "You shouldn't make negative statements since I'm trying to help you."

"Tell me what I said that made you feel uncomfortable." *This statement uses the therapeutic technique of exploring to ask the client to explain her feelings. This can help the client view the situation objectively, enabling the nurse to determine the client's thoughts and promoting trust between the client and nurse

A nurse is caring for a client who has borderline personality disorder and is expressing concern about needing prolonged hospitalization. Which of the following statements should the nurse provide? A. "You should focus on getting better right now." B. "Why do you think you'll be hospitalized for a long time?" C. "All of your needs will be taken care of while you are in the hospital." D. "Tell me what concerns you most about being hospitalized."

"Tell me what concerns you most about being hospitalized." *Clients with borderline personality disorder have a difficult time identifying their feelings. This response uses open0ended therapeutic communication, which allows the client to focus on concerns about hospitalization and encourages verbalization of feelings

A nurse is caring for a client who has bipolar disorder. After the client is prescribed lithium, his adult child states, "I'm upset that my father is taking this medication." Which of the following responses should the nurse make? A. "It will be alright. You father's provider knows what she is doing." B. "You should be more concerned about your father's mania, which puts him at risk for injury." C. "Tell me what worries you have about your father taking this medication." D. "This is an important medication that will treat your father's condition."

"Tell me what worries you have about your father taking this medication." *This response is therapeutic because it attempts to clarify the family member's concerns and focuses the conversation on the current topic

A nurse is collecting data from a client who has schizophrenia. The client suddenly stops talking and begins staring intently at a chair in the corner of the room. Which of the following responses should the nurse make? A. "Please try to focus on our conversation." B. "There is nothing over there except a chair." C. "Tell me what you are seeing by that chair." D. "Whatever you are seeing by chair is not real."

"Tell me what you are seeing by that chair." *The nurse should recognize that the client might be experiencing a hallucination and should collect further data about the situation. This response directly asks the client about the hallucination and promotes further communication about the possible perceptual alteration

A nurse is caring for a client who is postoperative following an amputation of the left lower leg. The client states, "I can't believe this happened to me. I don't deserve this." Which of the following responses should the nurse make? A. "Tell me what you're feeling about what has happened?" B. "The feelings you're having are normal following an amputation." C. "I agree with you. You did not deserve this." D. "What makes you say that you don't deserve this?"

"Tell me what you're feeling about what has happened?" *The nurse should use therapeutic communication when discussing the client's concerns. This statement is an example of exploring, which encourages the client to talk further about personal feelings and perceptions

A nurse is caring for a client who has schizophrenia. The client states, "Aliens came into my room last night and took a sample of my blood." Which of the following responses should the nurse make? A. "Aliens do not exist." B. "Has your daughter had her baby?" C. "Do you mean to say a laboratory technician drew your blood last night?" D. "That does not sound real."

"That does not sound real." *The nurse is voicing doubt with this response, which expresses uncertainty regarding the reality of the client's conclusion of the hallucination. This is a therapeutic response because the statement allows the client to expand upon the earlier statement, which allows exploration of the client's thought processes

A nurse is caring for a client who reports that the television set in the room is really a 2-way radio states, "Voices are coming from the TV, and everything we say in this room is being recorded." Which of the following responses should the nurse make? A. "What we say is not being recorded." B. "Let's ignore the voices and talk about something else." C. "That must be very frightening." D. "Why do you think the TV is a 2-way radio"

"That must be very frightening." *The nurse should respond to the client's delusion in a a calm and empathetic manner. By acknowledging to the client that the delusion must be frightening, the nurse promotes the nurse-client relationship

A mental health nurse is reviewing a process recording of a therapy session with a client. Which of the following statements should the nurse identify as an example of the communication technique of reflection? A. "I notice you are pulling on your hair when we discuss your dismissal." B. "That statement made by the other client appears to have upset you." C. "Since writing in your journal is frustrating, we should look at this activity more closely." D. "Give me an example of a time when you felt no one understood you."

"That statement made by the other client appears to have upset you." *Reflective statements are useful in assisting a client with identifying emotions and ideas. This therapeutic communication technique validates the client's emotions and encourages the client to reflect more deeply on the emotion

A nurse in a health clinic is reinforcing teaching with a client about binge eating disorder. Which of the following client statements indicates an understanding of the teaching? A. "This problem is caused by a slow metabolism." B. "The abdominal pain I often have is due to the amount of food that I eat." C. "Most of my weight gain is water weight." D. "At least I do not need to worry about being physically ill."

"The abdominal pain I often have is due to the amount of food that I eat." *Gastrointestinal complications can arise for clients who have binge eating disorder due to the larger than normal amount of food they consume. Other manifestations include constipation, diarrhea, urgency, and a feeling of anal blockage

A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "Care during the continuation phase focuses on treating continued manifestations of MDD." B. "The treatment of MDD during the maintenance phase lasts for 6 to 12 weeks." C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." D. "Medication and psychotherapy are most effective during the acute phase of MDD."

"The client is at greatest risk for suicide during the first weeks of an MDD episode." *The client is at greatest risk of suicide during the acute phase of MDD *The focus on the continuation phase is relapse prevention. Treatment of manifestations occurs during the acute phase of MDD *The maintenance phase of treatment for MDD can last for 1 year or more *Medication therapy and psychotherapy are used during the continuation phase to prevent relapse of MDD

After signing a contract that he will no longer smoke in his room, the patient violates the contract. The contract consequences include confiscation of smoking materials and mandatory supervision for future smoke breaks. How should the nurse appropriately address the patient's behavior? A. "Why are you smoking in your room when you know it is not allowed?" B. "The contract states that if you smoke in your room, you must give me your smoking materials. Let me have them, please." C. "Okay, Larry, give me your cigarettes and lighter now." D. "I am going to give you one more chance, Larry. Let's see if you can live up to the contract."

"The contract states that if you smoke in your room, you must give me your smoking materials. Let me have them, please." *Reminding the patient of contract violation and the penalty attached should be done before taking the cigarettes. This approach is fair and puts the blame for the consequence on th offender. Provider the patient with the opportunity to "explain" the actions does not conform to the agreed-on contract. Providing additional opportunities for compliance does not support the contract and may encourage manipulative behavior

A nurse is reinforcing teaching with a client who reports depression and has a new prescription for an SSRI medication. Which of the following statements should the nurse make? A. "You should avoid foods with tyramine while taking this medication." B. "If the adverse effects are too bothersome, stop taking the medication." C. "Drinking alcohol is allowed with this type of medication." D. "The effect of the medication may take several weeks to be felt."

"The effect of the medication may take several weeks to be felt." *The nurse should reinforce with the client that the therapeutic effect of SSRIs may take 1 to 4 weeks to be felt. If no effect is felt by 4 weeks, the client should notify the provider, and a change in dosage or medication may be prescribed. The client should continue to take the medication as directed, even if symptoms improve. A relapse of depression can occur if the medication is stopped

A nurse is caring for a client who has schizophrenia. Which of the following client statements should the nurse identify as a persecutory delusion? A. "A tornado is going to wipe us all out in 9 days." B. "My brain is dead, and my body is slowly rotting away." C. "The government is after me because I know top-secret information." D. "The TV is purposely playing commercials for things I don't like."

"The government is after me because I know top-secret information." *The nurse should identify this statement as an indication of a persecutory delusion

What is the appropriate nursing response when a patient with alcohol use disorder asks, "What is the purpose of Antabuse?" A. "It blocks the craving for alcohol." B. "The medication causes unpleasant symptoms when you drink." C. "The drug keeps you from having seizures." D. "It controls symptoms of nausea, vomiting, pain, or cramps."

"The medication causes unpleasant symptoms when you drink." Disulfiram (Antabuse) can cause chest pain, nausea and vomiting, hypotension, weakness, blurred vision, and confusion if alcohol is consumed after taking the medication. (1) Antabuse does not block the craving for alcohol. Naltrexone (ReVia) can be used to block the craving for alcohol. (3, 4) Antabuse does not control nausea and vomiting, pain, cramps, or seizures.

Which patient statement regarding antipsychotic medication indicates a need for further teaching? A. "The medication helps me think more logically." B. "The medication makes my mouth dry." C. "The medication improves my mood." D. "The medication helps stop the voices."

"The medication improves my mood." *Antipsychotic medications do not function as mood elevators. (1, 4) They should help the patient have less thought disorder and less distortion in sensory perception. (2) A side effect is dry mouth.

A nurse is reinforcing teaching with a client who recently completed detoxification from alcohol and has a new prescription for acamprosate. Which of the following statements should the nurse make? A. "You will get very sick if you drink alcohol while taking this medicaion. B. "The medication will be administered as a subcutaneous injection." C. "You should take this medication on an empty stomach." D. "The medication might cause you to have episodes of diarrhea."

"The medication might cause you to have episodes of diarrhea." *The nurse should instruct the client that an adverse effect of acamprosate is diarrhea

Donepezil (Aricept) has been prescribed for a patient with Alzheimer disease (AD). Which statement indicates that the patient and spouse understand teaching about the medication? A. "It is best to take the medication at bedtime." B. "The medication will interact with dark leafy greens." C. "Taking the medication with a citrus beverage should improve absorption." D. "The medication should be take with meals."

"The medication should be take with meals." *Donepezil (Aricept) is used in the management of AD. It has been shown to elevate acetylcholine levels in the brain and will slow the progression of the condition. The medications should be taken with meals to reduce gastrointestinal distress

A nurse is providing teaching to a client who has social anxiety disorder and a new prescription for paroxetine. Which of the following statements should the nurse include in the teaching? A. "You can take this medication when needed." B. "The medication takes a few weeks to build up in your system." C. "You should plan to take this medication for 6 months." D. "Relapsing after withdrawing from this medication is rare."

"The medication takes a few weeks to build up in your system." *The nurse should inform the client that initial effects of paroxetine take about 4 weeks to develop. Optimal effects of the medication can be seen in 8 to 12 weeks

A nurse is reinforcing teaching with the partner of a client who has conversion disorder. Which of the following statements by the partner shows an understanding of the teaching? A. "My partner is pretending to be ill to get attention." B. "My partner is purposely making our child sick." C. "The stress of losing our child caused my partner to go blind." D. "My partner is worried that he has cancer, even though his tests are normal."

"The stress of losing our child caused my partner to go blind." *The nurse should explain to the partner that conversion disorder manifests as deficits in motor or sensory functions. Emotional conflict or stress is reflected in physical manifestations that can include paralysis, blindness, movement disorder, numbness, paresthesia, loss of hearing, or episodes resembling epilepsy

A nurse is reinforcing teaching to a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy? A. "Even if my anxiety improves I will need to continue this therapy for 6 weeks." B. "The therapist will focus on my past relationships during our sessions." C. "Psychoanalysis will help me reduce my anxiety by changing my behaviors." D. "This therapy will address my conscious feelings about stressful experiences."

"The therapist will focus on my past relationships during our sessions." *Classical psychoanalysis places a common focus on past relationships to identify the cause of the anxiety disorder *Classical psychoanalysis is a therapeutic process that requires many sessions over months to years *Classical psychoanalysis focus on identifying and resolving the cause of the anxiety rather than changing behavior *Classical psychoanalysis assesses unconscious, rather than conscious, thoughts and feelings

The depressed patient who has been taking amitriptyline (Elavil) for the past 2 weeks complains of still feeling depressed and wants to abandon the drug. How should the nurse respond? A. "I will ask the physician about a new order for a different drug." B. "You probably should quit taling Elavil if it is not helping you." C. "Sometimes drinking a small glass of wine with meals helps." D. "These drugs take several weeks to become effective."

"These drugs take several weeks to become effective." *Tricyclics may take up to 4 weeks before patients experience symptom relief. The patient has not been taking the medication long enough to request a new order. The nurse should not encourage the patient to discontinue the medication. This medication should not be combined with alcohol

A nurse is interviewing a client whose partner died 6 months ago. The client states, "I feel so lonely and empty inside." Which of the following responses should the nurse make? A. "I know how you feel." B. "Have you thought about remarrying?" C. "This loss must be tragic for you." D. "Your partner is in a better place now."

"This loss must be tragic for you." *The nurse should respond by restating how the client feels and allowing the client to express feelings about the loss

A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "This medication increases the release of serotonin and norepinephrine." B. "I should tell the client about the likelihood of insomnia while taking this medication." C. "This medication is contraindicated for clients who have an eating disorder." D. "Sexual dysfunction is a common adverse effect of this medication."

"This medication increases the release of serotonin and norepinephrine." *Mirtazapine provides relief from depression by increasing the release of serotonin and norepinephrine *Tell the client about the likelihood of drowsiness rather than insomnia when taking this medication *Buproprion, rather than mirtazapine, is contraindicated in clients who have an eating disorder *Sexual dysfunction is an adverse effect of SSRIs rather than mirtazapine

A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for venlafaxine. Which of the following statements should the nurse make? A. "This medication is only for short-term use" B. "This medication can be taken on an as-needed basis." C. "This medication will effectively reduce your physical manifestations of anxiety." D. "This medication should not be stopped abruptly."

"This medication should not be stopped abruptly." *The nurse should instruct the client that stopping venlafaxine abruptly will lead to manifestations of withdrawal.

The nurse is talking to a teenager who says, "Marijuana is not a big deal. It should be legalized." What is the best response? A. "Actually marijuana is a gateway substance that can lead to more serious drug use." B. "Well, marijuana does help control nausea for chemotherapy patients." C. "You should really talk to your parents about this and get their opinions." D. "So it sounds like you have some firsthand experience with marijuana."

"You seem upset by this; tell me about your concerns."

A nurse is reinforcing teaching with a cliet who has alcohol use disorder and a new presciption for carbamezepine. Which of the following information should the nurse include? A. "This medication will help prevent seizures during alcohol withdrawal." B. "Taking this medication will decrease your cravings for alcohol." C. "This medication maintains your blood pressure at a normal level during alcohol withdrawal." D. "Taking this medication will improve your ability to maintain abstinence from alcohol."

"This medication will help prevent seizures during alcohol withdrawal." *Carbamazepine is used during withdrawal to decrease the risk for seizures *Carbamazepine is used to promote safe withdrawal rather than to decrease cravings for alcohol *Clonidine or propranolol is used during withdrawal to depress the autonomic response and its effect on blood pressure *Carbamazepine is used to promote safe withdrawal rather than abstinence

The nurse is caring for a patient with a recent diagnosis of schizophrenia. His wife asks how long it will be until her husband is cured. What reponse by the nurse is most appropriate? A. "Unfortunately, there is no cure, but the condition can be managed." B. "It will take approximately 1 to 2 months of medication therapy to alleviate your husband's symptoms." C. "We cannot consider your husband cured until he has been symptom free for at least 1 year." D. "There is no way to predict his outcome during his initial episode."

"Unfortunately, there is no cure, but the condition can be managed." *Schizophrenia can be managed with therapy and medications. It cannot be permanently cured. Evidence suggests that ealy treatment for schizophrenia improves long-term prognosis. Patients who are treated for first episodes generally respond to the therapeutic effects and require lower doses of antipsychotic medications. After starting a medicaiton, the patient should be monitored for 2 to 4 weeks for therapeutic response

A nurse in an acute mental health facility is caring for a client who has schizophrenia. The client asks the nurse, "Can I vote in the upcoming presidential election?" Which of the following responses should the nurse make? A. "Why do you want to vote while you are in the hospital?" B. "I wouldn't worry about voting right now." C. "We can work together to find out how you can get a mail-in ballot." D. "You'll have a lot more opportunities to vote after you get better."

"We can work together to find out how you can get a mail-in ballot." *The nurse provides a therapeutic response by suggesting collaboration and formulating a plan of action that will result in giving the client information and addressing the client's need

A nurse on a mental health unit is caring for a client who asks the nurse out to dinner. Which of the following responses should the nurse provide? A. "You should ask one of the other client if they'd like to go to dinner with you." B. "Why are you asking me out to dinner?" C. "We have a professional relationship, not a personal relationship." D. "We should discuss this some other time."

"We have a professional relationship, not a personal relationship." *This statement is therapeutic because it clarifies the purpose of the relationship between the nurse and the client

A nurse is caring for a client who returns to the unit from day pass 2 h ours late. The client has slurred speech, and the nurse smells alcohol on the client's breath. What should the nurse say to the client in response to this situation? A. "Why are you returning late from your day pass?" B. "How much did you drink? You know drinking is against the rules." C. "We will need to discuss your actions after you've had a chance to sleep." D. "I'm disappointed that you were not more responsible while on a day pass."

"We will need to discuss your actions after you've had a chance to sleep." *This response is therapeutic because the client is unable to process this behavior while under the influence of alcohol

A nurse is reinforcing teaching about decreasing codependent behaviors with the family of a client who has alcohol use disorder. Which of the following statements by a family member indicates an understanding of the teaching? A. "We will help her financially if she loses her job." B. "We will not hold her responsible for her alcohol use." C. "We will routinely search for and remove any alcohol in her home." D. "We will not let our moods be changed by her behavior."

"We will not let our moods be changed by her behavior." *The nurse should explain to the family that alcohol use is self-inflicted and that the client must take responsibility for her actions. The family should not allow the client's dysfunctional behavior to control their environment. Establishing boundaries with the client is the family's first step in reducing the codependent behaviors

A nurse is reinforcing teaching with the family of a client who is scheduled for electroconvulsive therapy (ECT). Which of the following statements made by a family member indicates an understanding of ECT? A. "We are so glad there are no physical side effects of shock treatment." B. "Thank goodness there is no permanent memory loss." C. "Cardiac dysrhythmias can persist for several weeks." D. "We won't be alarmed if there is some confusion after the treatment."

"We won't be alarmed if there is some confusion after the treatment." *It is common following ECT for a client to experience confusion and disorientation

A nurse is reinforcing teaching with the parent of a child who has a new prescription for methylphenidate to treat ADHD. Which of the following instructions should the nurse include in the teaching? A. "Weigh your child 3 times per week." B. "Expect your child to experience dark-colored stools." C. "Administer this medication at bedtime." D. "You should limit your child's intake of caffeine."

"Weigh your child 3 times per week." *The nurse should instruct the parent to weigh the child 2 to 3 times per week. Weight loss is an adverse effect of this medication. If significant weight loss occurs, the parent should notify the provider.

A nurse is caring for a client who was hospitalized several days ago following a suicide attempt. The client informs the nurse, "I do not want visitors today because I look and feel terrible." Which of the following responses should the nurse make? A. "That is silly. You look just fine to me." B. "Nobody expects you to look good in a hospital." C. "I understand. Would you like to wash your hair?" D. "Would you like to talk about why you feel this way?"

"Would you like to talk about why you feel this way?" *This response by the nurse acknowledges the client's feelings and conveys the ability to understand them, which promotes a trusting relationship between the client and the nurse

A nurse is collecting data from a newly admitted client who has schizophrenia. The client suddenly looks at an empty chair and appears to be listening to something. Which of the following responses should the nurse make? A. "I thought I heard something too." B. "Is someone telling you something?" C. "What are you hearing?" D. "There is nobody in that chair for you to listen to."

"What are you hearing?" *This open-ended question allows the nurse to find out what the client is hearing without validating the hallucination as real. The nurse should watch the client for anxiety or fear and ensure that the hallucination is not commanding the client to hurt self or others. After an assessment of the client's hallucinations is complete, the nurse can develop a plan to decrease the hallucinations.

A nurse is caring for an adolescent male client who has anorexia nervosa. The client asks, "Have I done any permanent damage to my body?" Which of the following responses should the nurse make? A. "What concerns do you have about your physical health?" B. "Let's wait to discuss that after you're feeling better." C. "Unconsciously, you're saying that you're worried about your physical appearance." D. "I'm glad you're concerned about the physical effects of your illness."

"What concerns do you have about your physical health?" *The nurse should use therapeutic communication when discussing the client's concerns. This statement by the nurse is an example of exploring, which encourages the client to talk further about personal feelings and perceptions

A nurse is caring for a client who is receiving cognitive-behavioral therapy. The client tells the nurse, "Nothing good ever happened during my marriage." When using cognitive reframing, which of the following responses should the nurse provide? A. "Let's discuss what you considered to be negative about your marriage." B. "What activities do you enjoy that take your mind off your marriage experience?" C. "What did you learn from your marriage to help you in the future?" D. "Only you can understand how your marriage negatively affected your life."

"What did you learn from your marriage to help you in the future?" *Cognitive-behavioral therapy, specifically cognitive reframing, asks the client to restructure thoughts to try to learn from situations perceived as negative. The intended purpose is to help the client identify misconceptions and work toward developing more accurate and positive perceptions. This response encourages the client to look at the situation more positively to find the benefits of experience

The nurse is making a home visit to an elderly patient with Alzheimer disease. The patient's wife says, "Jim is more confused compared to usual." What is the best response? A. "It's hard to see someone that you love deteriorate." B. "What kind of changes are you seeing?" C. "When was the last time your husband saw a health care provider? D. "With Alzheimer disease, the symptoms do worsen."

"What kind of changes are you seeing?"

After detoxification from substance abuse, the patient says, "I feel better than I have in years! All I needed was some rest. I am not an alcoholic." Which response is best for the nurse to make? A. "What were you doing that got you admitted to the detoxification center?" B. "Alcoholism has many definitions. What is yours?" C. "Admitting to alcoholism is hard." D. "Alcoholism has ruined your life. How can you say you are not an alcoholic?"

"What were you doing that got you admitted to the detoxification center?" *Confronting denial and encouraging self-diagnosis is the point of the treatment phase after detoxification. Asking for the patient's definition of alchoholism allows for the patient to intellectualize the problem. Stating that alcoholism is "hard" is a sympathetic and unhelpful response. "Alcoholism has ruined your life" is accusatory and counterproductive

A nurse is caring for a client who states, "I'm so stressed at work because of my coworker. I am expected to finish others' work because of their laziness!" When discussing effective communication, which of the following statements by the client to the coworker indicates client understanding? A. "You really should complete on your own work. I don't think it's right to expect me to complete your responsibilities." B. "Why do you expect me to finish your work? You must realize that I have my own responsibilities." C. "It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor." D. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities."

"When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities." *This response demonstrates assertive communication, which allows the client to state their feelings about the behavior and then promote a change *(A) This statement is an example of disapproving/disagreeing, which can prompt a defensive reaction and is therefore nontherapeutic *(B) This statement uses a "why" question, which implies criticism and can prompt a defesnive reaction and is therefore a defensive reaction and is therefore nontherapeutic *(C) This statement is aggressive and threatening, which can prompt a defensive reaction and is therefore nontherapeutic

During data collection, the patient's son tells the nurse, "Mom can remember her name, but she doesn't seem to know where she is." Based on this information, which question should the nurse ask first? A. "How does she like to be addressed?" B. "When did you first notice this?" C. "What kind of medications does she take?" D. "When did she last see the health care provider?"

"When did you first notice this?"

You are taking a history for a patient who needs emergency surgery and who freely admits to using marijuana, alcohol, cocaine, and hallucinogens. Which is the appropriate nursing question? A. "Does your partner know that you are using drugs?" B. "When was the last time you drank or took a substance?" C. "How frequently are you using thse drugs and alcohol?" D. "Have you ever tried to get treatment for your substance use?"

"When was the last time you drank or took a substance?" *The most important issue in this emergency situation is to determine the last use of substances so that the health care team is aware of drug-drug interactions or the possibility of withdrawal symptoms. (1) This is a not an appropriate question at this time. (3, 4) Direct and nonjudgmental questioning is best for obtaining information. Other questions would also be included to develop short- and long-term interventions for this patient after the emergency situation is resolved.

A patient has been admitted to the unit for a medically managed withdrawal from diazepam. During her third day on the unit, she angrily tells the nurse, "I know how it is. You're all writing lies about me in my chart. None of you care anything about me. You just want to get rid of me." Which response by the nurse is most therapeutic? A. "What do you think we're all saying about you?" B. "Nobody would write lies about you in your chart." C. "I'm not sure what you're referring to." D. "Would you like to talk to me some more about this?"

"Would you like to talk to me some more about this?" *The most therapeutic response would attempt to get the patient to verbalize her concerns. The nurse should not play dumb, encourage the delusion, or ignore the patient's concerns.

The nurse is doing discharge teaching for a manic patient. The patient asks., "Will I have to take lithium forever?" The best answer would be A. "No, only until your symptoms are under control." B. "Yes, you will most likely need to take it for your lifetime." C. "Possible your health care provider will let you discontinue after 4-6 months." D. "No, most patients can usually do without it after about a year."

"Yes, you will most likely need to take it for your lifetime."

A home health nurse is talking with the partner of a client who has dementia. Which of the following statements by the partner indicates that the client is displaying signs of apraxia? A. "Yesterday, my partner put on a jacket upside down." B. "My partner has trouble reading the newspaper." C. "My partner often repeats words." D. "Last week, my partner did not recognize the sound of the alarm clock."

"Yesterday, my partner put on a jacket upside down." *The nurse should recognize that this statement is an indication that the client is experiencing apraxia (the lack of ability to accomplish once known tasks). This manifestation is considered a cognitive deficit because there is no loss of motor or sensory ability.

A nurse is orienting a new client to a mental health unit. Which of the following statements should the nurse make when explaining the unit's community meetings? A. "You and a group of other clients will meet to discuss your treatment plans." B. "Community meetings have a specific agenda that is established by staff." C. "You and the other clients will meet with staff to discuss common problems." D. "Community meetings are an excellent opportunity to explore your personal mental health issues."

"You and the other clients will meet with staff to discuss common problems." *Community meetings are an opportunity for clients to discuss common problems or issues affecting all members of the unit *Individual treatment plans druing individual therapy rather than a community meeting *Community meetings can be structured so that they are client-led with decisions made by the group as a whiole *Personal mental health issues are discussed during individual therapy rather than a community meeting

After having refused lunch and diner because her "regular" char was occupied at breakfast, the resident in a long-term care facility asks for a snack. How should the nurse respond? A. "You are hungry now. Is there something else you could have done earlier besides refusing to eat?" B. "Here is your snack. Maybe you won't be so quick to refuse meals the next time you don't get you way." C. "Refusing meals is not the answer. You must eat." D. "Tell me why you left the dining room without eating."

"You are hungry now. Is there something else you could have done earlier besides refusing to eat?" *After acute anxiety passes, the nurse should focus on helpling the resident recognize the behavior that was exhibited and how to deal more effectively with the anxiety. Scolding the patient, attempting to induce guilt, or cauing the patient to dwell on the trigger do not redirect the patient to consider different behaviors

A nurse is caring for a client who has schizophrenia and has been admitted to the mental health unit. The client has a history of aggression and has been continually pacing the hallway in an agitated manner over the past hour. Which of the following responses should the nurse make? A. "It's a beautiful day outside. Let's take a walk together." B. "Sit down so we can try a relaxation exercise." C. "Would you like your antianxiety medication now?" D. "You are pacing back and forth. Can you tell me what you are feeling?"

"You are pacing back and forth. Can you tell me what you are feeling?" *The first action the nurse should take using the nursing process is to collect data from the client. By asking the client to identify feelings of anxiety, the nurse promotes trust and can assist the client with decreasing anxiety before an episode of aggression occurs

A nurse is reinforcing teaching with a client who has major depressive disorder and is scheduled to begin electroconvulsive therapy (ECT). Which of the following pieces of information should the nurse include? A. "If you're trying a benzodiazepine medication, you should take it before the procedure." B. "You can expect to wake up about 15 minutes after the procedure." C. "After the first procedure, you should expect to have ECT sessions monthly for a year." D. "ECT is the primary treatment for most clients who have depression."

"You can expect to wake up about 15 minutes after the procedure." *A client who undergoes ECT usually wakes up about 15 minutes after the procedure and can be disoriented for several hours after.

The manipulative patient approaches the nurse and says, "I know it's too early to give me my pain medication, but you are the only one who seems to care. Could you give me my pain medication now?" Which response is best? A. "The charge nurse is very stringent aout scheduled medications. She would be very angry with me if I gave you the medication now." B. "I know how it is when you are in pain. I'll give you your medication early." C. "You medication is due in 2 h. I will be glad to give it to you on schedule." D. "It makes me feel good to know you are aprpeciative of our care. Here is your medication."

"You medication is due in 2 h. I will be glad to give it to you on schedule." *Setting clear limits is important when managing manipulative patients. Once limits are set, it is important to maintain them. Blaming the charge nurse provides incentive for further manipulative behaviors. The nurse telling the patient that they know what it is like when they are in pain is not accurate or therapeutic. Providing the medication early likely does not follow the prescribed plan

A nurse on a psychiatric unit is talking with a client who makes a sexual advance toward the nurse. Which of the following responses should the nurse provide? A. "It's normal for you to have sexual feelings toward the staff." B. "You need to stop any type of sexual advances." C. "This behavior is unacceptable while I am your nurse." D. "What would your family think of this type of behavior?"

"You need to stop any type of sexual advances." *The nurse should clearly identify behavior expectations to help promote and maintain appropriate boundaries

A nurse is collecting data from a client who has been using a nicotine transdermal patch for smoking cessation. The client reports itching of the skin where the patch is applied. Which of the following statements should the nurse make? A. "You should change the location of the patch on your body." B. "Decreasing the strength of the patch should stop the itching." C. "You should discontinue using the patch." D. "This is an adverse effect of the patch that will subside in time."

"You should discontinue using the patch." *The nurse should instruct the client to discontinue the patch if persistent local reactions such as erythema, itching, or edema is experienced

A nurse is reinforcing teaching with a client who has a prescription for clozapine. Which of the following statements should the nurse include in the teaching? A. "You should have your white blood cell count checked once per week for 6 months." B. "You should check your weight every 3 days for weight loss." C. "You might experience frequent loose stools." D. "You might experience ringing in your ears."

"You should have your white blood cell count checked once per week for 6 months." *The nurse should instruct the client to complete laboratory testing of WBCs and neutrophils every week for 6 months

The patient is ready to be discharged. The nurse teaches him about his antipsychotic medication and he asks, "What will happen if I stop taking my medication when I go home?" Which is the best reply? A. "You should never stop taking your medication." B. "Someday you may be able to without the medication." C. "If you can get organized and reduce stress, perhaps you can get along without it." D. "If you stop taking your medication, the symptoms will probably return."

"You should never stop taking your medication."

A nurse is caring for a client who has early stage Alzheimer's disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication? A. "You should avoid taking over-the-counter acetaminophen while on donezepil." B. "You should take this medication before going to bed at the end of the day." C. "You will be screened for underlying kidney disease prior to starting donezepil." D. You should stop takine donezepil if you experience nausea or diarrhea."

"You should take this medication before going to bed at the end of the day." *Clients should take donezepil at the end of the day, just before going to bed, with or without food. *Clients taking donepezil should avoid NSAIDs, rather than acetaminophen, due to risk for gastrointestinal bleeding *Clients should be screened for underlying heart and pulmonary disease, rather than kidney disease *Gastrointestinal adverse effects are common with donepezil and can result in a dosage reduction

A nurse is caring for a client who lost their mother to cancer last month. The client states, "I'd still have my mother if the doctor would have made a diagnosis sooner." Which of the following responses should the nurse make? A. "You sound angry. Anger is a normal feeling associated with loss." B. "I think you would feel better if you talked about your feelings with a support group." C. "I understand just how you feel. I felt the same when my mother died." D. "Do other members of your family also feel this way?"

"You sound angry. Anger is a normal feeling associated with loss." *This is a therapeutic reponse for the nurse to make. This reposne acknowledges the client's emotion and privides education on the normal grief response. *(B) This response offers advice, which is a nontherapeutic technique *(C) This response minimizes the client's feelings and takes the focus away from the client, which are nontherapeutic communication techniques *(D) This reponse takes the focus away from the client, which is a nontherapeutic communication technique.

A newly admitted client who has major depressive disorder states to the nurse, "I'm a failure. I can't even cope with little things anymore." Which of the following responses should the nurse make? A. "What happened in your life to make you feel like such a failure?" B. "You sound like you're feeling pretty overwhelmed right now." C. "Do you feel like you don't deserve to be good to yourself?" D. "I know you feel like that now, but you'll feel differently when you get better."

"You sound like you're feeling pretty overwhelmed right now." *This response by the nurse acknowledges the client's feeling and attempts to convey the ability to understand them, which promotes a trusting relationship between the client and the nurse

A nurse is reinforcing teaching with a client who is scheduled for electroconvulsive therapy (ECT) to treat major depression. Which of the following pieces of information should the nurse include? A. "You will be awake during the procedure." B. "You will experience a seizure during this procedure." C. "You can't eat or drink anything for 24 hours before the procedure." D. "You are not required to sign an informed consent form for this procedure."

"You will experience a seizure during this procedure." *The nurse should inform the client that the procedure will involve a seizure. ECT induces a generalized seizure of the brain by electrical current. ECT increases neurotransmitters in the brain, which can assist with treating the client's depression

A nurse is reinforcing teaching with a client who has agoraphobia about systemic desensitization. Which of the following comments should the nurse include in the teaching? A. "You will watch from a secure location as your therapist goes to public spaces." B. "You will start your therapy by staying in a public space until your anxiety decreases." C. "You will be instructed to say "Stop!" out loud when you become anxious in public spaces." D. "You will slowly be exposed to increasing levels of public spaces."

"You will slowly be exposed to increasing levels of public spaces." *The nurse should inform the client that, using systemic desensitization, she will be gradually exposed to the feared situation under controlled conditions until she learns to overcome the anxious response

A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication? A. "I wish you would not make me angry. B. "I feel angry when you leave me." C. "It makes me angry when you interrupt me." D. "You'd better listen to me."

"You'd better listen to me." *This statement implies a threat and a lack of respect for another individual. The other 3 statements do not imply a threats, nor do they indicate a lack of respect for another individual.

A nurse is assisting with the admission of a client who has a hip fracture to the medical surgical care unit. The client states, "I've never been in the hospital before, and I'm feeling a lot of anxiety." Which of the following responses should the nurse make? A. "You're feeling anxious about being in the hospital for the first time." B. "Anxiety while in the hospital is a feeling many people experience." C. "Why do you think you feel anxious about being in the hospital?" D. "What activities do you enjoy when you are not in the hospital?"

"You're feeling anxious about being in the hospital for the first time." *The nurse should therapeutic communication when discussing the client's concerns. This statement is an example of restating, which encourages the client to continue talking and clarify any misunderstandings if necessary

A nurse is caring for a client who left the facility without permission and has had outside privileges revoked for 1 week. The client asks the nurse if she can take a short walk outside the facility. Which of the following responses should the nurse provide? A. "Your privileges have been revoked. I'd be glad to help you find something to do inside the unit." B. "I think it would be good for you to take a walk, but your doctor has take away your privileges." C. "You decided to leave the hospital without permission. Why are you asking to go outside today?" D. "We shouldn't discuss this. Let's talk about what you want to do when you are discharged."

"Your privileges have been revoked. I'd be glad to help you find something to do inside the unit." *This response demonstrates the technique of offering self to the client. It reinforces the reality of the client's current situation, offers the client another option for a permitted activity, and conveys the nurse's willingness to spend quality time with the client

A nurse us reviewing informaiton about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "ECT is the recommended initial treatment for bipolar disorder." B. "ECT is contraindicated for clients who have suicidal ideation." C. "ECT is effective for clients who are experiencing severe mania." D. "ECT is prescribed to prevent relapse of bipolar disorder."

. "ECT is effective for clients who are experiencing severe mania." *ECT is appropriate for the treatment of severe mania associated with bipolar disorder *Pharmacological intervention is the recommended initial treatment for bipolar disorder *ECT is effective for clients who have bipolar disorder and suicidal ideation *ECT is prescribed for clients experiencing an acute episode of bipolar disorder rather than for the prevention of relapse

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse is not acceptable? A. "Stop screaming, and walk with me outside." B. "Why are you so angry and screaming at everyone?" C. "You will not get your way by screaming." D. "What was going through your mind when you started screaming?"

. "Stop screaming, and walk with me outside." *This is an inappropriate therapeutic response. Setting limits and the use of physical activity (walking) to de-escalate anger is an appropriate intervention *(B)"Why" questions imply criticism and will often cause the client to become defensive *(C) This is a closed-ended, nontherapeutic statement *(D) The client is not ready to discuss this issue

A nurse is caring for a client who states, "I plan to commit suicide." Which of the following findings should the nurse identify as the priority? A. Client's educational and economic background B. Lethality of the method and availability of means C. Quality of the client's social support D. Client's insight into the reasons for the decision

. Lethality of the method and availability of means *The greatest risk to the client is self-harm as a result of carrying out a suicide plan The priority finding is to determine how lethal the method is, how available the method is, and how detailed the plan is

A nursing is preparing to administer alprazolam 4 mg PO divided equally every 12 hours for a client who has generalized anxiety disorder. The amount available is alprazolam 2 mg tab. How many tablets should the nurse administer per dose?

1 tablet

Approximately what percentage of the U.S. population is affected with schizophrenia? A. 1% B. 2% C. 3% D. 4%

1% *Schizophrenia is the most common though disorder. It is estimated that 1.1% of the general population is affected with schizophrenia, and in the United States this represents 3.5 million Americans

A patient verbalizes an overwhelming feeling of worthlessness, difficulty in making decisions or concentrating, and suicidal thoughts. You determine the suicide risk by asking which questions? (select all that apply) A. "Are you feeling suicidal?" B. "Do you have a plan for taking your life? C. "Why do you want to commit suicide?" D. "What would you accomplush by killing yourself?" E. "Do you drink or use drugs on a regular basis?" F. "Have you considered how your family would feel?" G. "Have you recently given away any of your belongings?"

1. "Are you feeling suicidal?" 2. "Do you have a plan for taking your life? 3. "Do you drink or use drugs on a regular basis?" 4. "Have you recently given away any of your belongings?" *Suicidal feelings, having a plan, and substance abuse are factors that increase the likelihood of suicide attempt. Giving away belongings is a sign of the patient saying goodbye. (3, 4, 6) The other questions are less about risk than they are about motivation. The psychiatrist or psychologist can pursue these issues because of the depth and follow-up that are required.

A nurse is caring for a client who in mechanical restraints. Which of the following statements should the nurse include in the documentation? (select all that apply) A. "Client ate most of their breakfast." B. "Client was offered 8 oz of water every hr." C. "Client shouted obscenities at assistive personnel." D. "Client received chlorpromazine 15 mg by mouth at 1000." E. "Client acted out after lunch."

1. "Client was offered 8 oz of water every hr." 2. "Client shouted obscenities at assistive personnel." 3. "Client received chlorpromazine 15 mg by mouth at 1000." *The amount and frequency of fluids, a description of the client's verbal communication, and the dosage and time of medication offered is objective data that should be documented *Document objective information regarding intake in the client's medical record "the client ate 70% of their breakfast." *Document objective information regarding the client's behavior in the client's medical record

A nurse is reinforcing teaching with the family of a client who has a substance use disorder. Which of the following statements by a family member indicates an understanding of the instruction? (Select all that apply) A. "We need to understand that our sibling is responsible for their disorder." B. "Eliminating codependent behavior will promote recovery." C. "Our sibling should participate in an Al-Anon group to assist with recovery." D. "The primary goal of treatment is abstinence from substance use." E. "Our sibling needs to discuss personal feelings about substance use to help with recovery."

1. "Eliminating codependent behavior will promote recovery." 2. "The primary goal of treatment is abstinence from substance use." 3. "Our sibling needs to discuss personal feelings about substance use to help with recovery." *Families should be aware of codependent behavior (enabling) that can promote substance use rather than recovery *Abstinence is the primary treatment goal for a client who has a substance use disorder *Clients must acknowledge their feelings about substance use as part of a substance use recovery program *Clients are not responsible for their disease but are responsible for their recovery *Al-Anon is a recovery group for the familu of a client, rahter than the client who has a substance use disorder

A nurse is discussing normal grief with a client wo recently lost a child. Which of the following statements made by the client indicates understanding? (Select all that apply) A. "I may experience feelings of resentment." B. "I will probably withdraw from others." C. "I can expect to experience changes in sleep." D. "It is possible that I will experience suicidal thoughts." E. "It is expected that I will have a loss of self-esteem."

1. "I may experience feelings of resentment." 2. "I will probably withdraw from others." 3. "I can expect to experience changes in sleep." *Suicidal ideations are associated with complicated grieving. The client who is experiencing a distorted or exaggerated grief response can direct anger towards themselves. Monitor the client for thoughts of suicide or self-injury *A client who is experiencing a complicated grief response commonly experiences a loss of self-esteem and a sense of worthlessness. These findings are not associated with normal grief

A nurse is discussin the use of methadone with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the instruction (select all that apply) A. "Methadone is a replacement for physical dependence to opioids." B. "Methadone reduces the unpleasant effects associated with abstinence syndrome." C. "Methadone can be used during opioid withdrawal and to maintain abstinence." D. "Methadone increases the risk for acetaldehyde syndrome." E. "Methadone must be prescribed and dispensed by an approved treatment center."

1. "Methadone is a replacement for physical dependence to opioids." 2. "Methadone reduces the unpleasant effects associated with abstinence syndrome." 3. "Methadone can be used during opioid withdrawal and to maintain abstinence." 4. "Methadone must be prescribed and dispensed by an approved treatment center." *Disulfiram, rather than methadone, places the client at risk for acetaldehyde syndrome if the client consumes alcohol while taking the medication

A nurse is collecting data from a client who has a major depressive disorder. The nurse should identify which of the following client statements as an overt comment about suicide? (select all that apply) A. "My family will be better off if I'm dead." B. "The stress in my life is too much to handle." C. "I wish my life was over." D. "I don't feel like I can ever be happy again. E. "If I kill myself then my problems will go away."

1. "My family will be better off if I'm dead." 2. "I wish my life was over." 3. "If I kill myself then my problems will go away." *These statements are overt commets about suicide in which the client directly talks about their perception of an outcome of their death. Monitor the client further for a suicide plan. the other 2 statements are covert comments in which the client identifies a problem but does not directly talk about suicide. Monitor the client further for suicidal ideation

A patient is considering having electroconvulsive therapy (ECT) to treat his severe depression. Which statement(s) indicate(s) the patient understands the procedure? (Select all that apply) A. "I will have treatments once every other month." B. "The shock will cause me to have a short seizure." C. "This treatment is often more successful than medications." D. "I will have to be hospitalized the day before and after the treatments for observation." E. "The treatments will be performed in the early morning hours."

1. "The shock will cause me to have a short seizure." 2. "This treatment is often more successful than medications." 3. "The treatments will be performed in the early morning hours." *ECT is the oldest form of brain stimulation therapy used for severe depression. After several regimens of medication are unsuccessful, or if the patient is severely depressed or actively suicidal, ECT is considered. Evidence suggests that ECT is more effecetive than pharmacotherapy. ECT consists of electric shock, delivered to the brain via electrodes applied to the temples. This shock artificially induces a grand mal seizure lasting 30 to 90 seconds. The patient typically receives 8 to 12 treatments spread over several weeks. ECT is frequently done on an outpatient basis in the early morning

A nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (select all that apply) A. "To check cognitive ability. I should ask the client to count backward by sevens." B. "To check affect, I should observe the client's facial expression." C. "To check language ability, I should instruct the client to write a sentence." D. "To check remote memory, I should have the client repeat a list of objects." E. "To check the client's abstract thinking. I should ask the client to identify our most recent presidents"

1. "To check cognitive ability. I should ask the client to count backward by sevens." 2. "To check affect, I should observe the client's facial expression." 3. "To check language ability, I should instruct the client to write a sentence." *asking the client to repeat a list of objects is appropriate to check immediate, rather than remote, memory *Asking the client to identify recent presidents is appropriate to check cognitive knowledge rather than abstract thinking

A nurse is obtaining a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse include? (Select all that apply) A. "What is your relationship like with your family?" B. "Why do you want to lose weight?" C. "Would you describe your current eating habits?" D. "At what weight do you believe you will look better?" E. "Can you discuss your feelings about appearance?"

1. "What is your relationship like with your family?" 2. "Would you describe your current eating habits?" 3. "Can you discuss your feelings about appearance?" *A nursing history of a client who has anorexia nervosa should include data collection of family and interpersonal relationships, the client's current eating habits, and the client's perception of the issue *Asking a "why" question promotes a defensive client response and is therefore nontherapeutic *(D) This question promotes cognitive distortion, places the focus on weight, and implies that the client's current appearance is not acceptable

The wife of a patient suggests that the patient may have a problem with substance use. Which assessment questions should you ask the patient? (Select all that apply) A. "What substances are you currently using?" B. "How often do you drink or use illicit substances?" C. "When dod you last drink or use drugs of any kind?" D. "How do you feel about people who use substances?" E. "Why does your wife think you have a substance abuse problem?" F. "Is there a family history of alcoholism or substance abuse?"

1. "What substances are you currently using?" 2. "How often do you drink or use illicit substances?" 3. "When dod you last drink or use drugs of any kind?" 4. "Is there a family history of alcoholism or substance abuse?" *Standard assessment questions include assessing what the patient takes, how often, and when. In addition, family history is important because of genetic and environmental influences and risk factors. (4) Eliciting feelings about others is not appropriate during the assessment or at any other time (the focus is never about the substance abuse issues of others). (5) Asking the patient to explain the wife's perceptions should be postponed until a psychologist, psychiatrist, or substance abuse counselor can have an in-depth discussion, preferably with the entire family.

A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements should the nurse make? (select all that apply) A. "When did you start heaing these things?" B. "The voices are not real, or else we would both hear them." C. "It must be scary to hear voices." D. "Are the voices you hear telling you to hurt yourself?" E. "Why are the voices talking to only you?"

1. "When did you start heaing these things?" 2. "It must be scary to hear voices." 3. "Are the voices you hear telling you to hurt yourself?" *Ask the client directly about the hallucinations *Focus on the client's feelings rather than agreeing with the client's hallcunications *Monitor for command hallucinations and the client's risk for injury to self or others *Do not argue with the client's view of the situation *Avoid asking a "why" question, which is nontherapeutic and can promote a defensive client response

A nurse is discussing acute vs. prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? (select all that apply) A. Chronic pain B. Depressed immune system C. Increased blood pressure D. Panic attacks E. Unhappiness

1. Depressed immune system 2. Increased blood pressure 3. Unhappiness *A depressed immune system, increased blood pressure, and unhappiness is an indicator of acute stress *Chronic pain and panic attacks indicates a prolonged or maladaptive stress response

A nurse is reinforcing teaching with a client who has intermittent explosive disorder about a new prescription for fluoxetine. Which of the following information should the nurse provide? (select all that apply) A. An adverse effect of this medication is CNS depression B. Administer the medication in the morning C. Monitor for weight loss while taking this medication D. Therapeutic effects of this medication while taking this medication E. This medication blocks the synaptic reuptake of serotonin in the brain

1. Administer the medication in the morning 2. Monitor for weight loss while taking this medication 3. This medication blocks the synaptic reuptake of serotonin in the brain *Fluoxetine should be administered in the morning due to the potential for insomnia. It can result in weight loss. And it works by blocking the synaptic reuptake of serotonin, allowing more serotonin to stay at the junction of the neurons *An adverse effect of fluoxetine is CNS stimulation rather than CNS depression *Initial therapeutic effects of fluoxetine occur in 1 to 2 weeks, with full effectiveness occurring by 12 weeks.

A nurse is discussing the factors for somatic symptom disorder with a newly licensed nurse. Which of the following risk factors should the nurse include? (Select all that apply) A. Age older than 65 years B. Anxiety disorder C. Childhood trauma D. Coronary artery disease E. Obesity

1. Anxiety disorder 2. Childhood trauma *Age 16 to 25 years, anxiety disorder, and childhood trauma are risk factors for somatic symptom disorder *CAD and Obesity are not risk factors

The nurse outlines the treatment for a person with anxiety disorders, which include(s) which of the following? (select all that apply) A. Anxiolytic medication B. Education about disorder C. Individual therapy D. Relaxation techniques E. Stress management

1. Anxiolytic medication 2. Education about disorder 3. Individual therapy 4. Relaxation techniques 5. Stress management *All options are aspects of the treatment of the person with anxiety disorders

The nurse is caring for a patient with suspected cocaine abuse. What would be appropriate for inclusion in the nursing care plan? (Select all that apply.) A. Expect the duration of the drug's effects to be several hours. B. Begin detoxification with a similar drug, as ordered. C. Assess for signs of impending seizures. D. Use restraints only if he poses a threat to himself or others. E. Keep the patient's environment as free of stimulation as possible.

1. Assess for signs of impending seizures. 2. Use restraints only if he poses a threat to himself or others. 3. Keep the patient's environment as free of stimulation as possible. *Cocaine is a central nervous system stimulant; use of cocaine results in extreme agitation and puts the patient at high risk for seizures. Impaired judgment can result in injury to self or others, but the patient should not be restrained unless absolutely necessary because of the extreme agitation that can result from cocaine use. Cocaine detoxification is not accomplished by use of controlled amounts of a similar drug, as is the withdrawal protocol for other drugs (e.g., benzodiazepines).

A nurse is heling evaluate the plan of care for a client who has antisocial personality disorder. Which of the following client actions indicates that he is making progress with the treatment? (select all that apply) A. Assisting another client who has depression to fill out a menu B. Nominating himself to chair the client government meeting C. Requesting a weekend pass to go home D. Serving as the judge for a unit talent show E. Informing the nurse that the staff provides excellent care to clients

1. Assisting another client who has depression to fill out a menu 2. Requesting a weekend pass to go home *Clients who have antisocial personality disorder tend to lack empathy for others and often display an inability to connect with others. Assisting another client indicates the client's willingness to help and connect with others and demonstrates rules and have a lack of respect for authority. Requesting a weekend pass indicates the client's willingness to follow unit rules and demonstrates progress with treatment

A nurse is assisting the charge nurse with a court-ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (select all that apply) A. Demonstrates extreme anxiety when placed in a social situation B. Often engages in magical thinking C. Attempts to convince other clients to relinquish their belongings D. Becomes agitated if personal area is not neat and orderly E. Blames others for personal past and current problems

1. Attempts to convince other clients to relinquish their belongings 2. Blames others for personal past and current problems *Exploitation and manipulation of others is an expected finding of antisocial personality disorder *Failure to accept personal responsibility is an expected finding of clients who have antisocial personality disorder *Anxiety in social situations is an expected finding of clients who have avoidant personality disorder *Magical thinking and odd beliefs are findings observed in clients who have schizotypal personality disorder *Perfectionism with a focus on orderliness and control is an expected finding of clients who have obsessive-compulsive personality disorder

A nurse is completing admission data collection for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (Select all that apply) A. Auditory hallucination B. Lack of motivation C. Use of clang associations D. Delusion of persecution E. Constantly waving arms F. Flat affect

1. Auditory hallucination 2. Use of clang associations 3. Delusion of persecution 4. Constantly waving arms *Lack of motivation, or avolition and flat affect are examples of negative symptoms

A nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the nurse identify as being effectively treated by first-generation antipsychotics? (select all that apply) A. Auditory hallucinations B. Withdrawal from social situations C. Delusions of grandeuer D. Severe agitation E. Anhedonia

1. Auditory hallucinations 2. Delusions of grandeuer 3. Severe agitation *First-generation antipsychotics have minimal effectiveness with negative symptoms of schizophrenia (social withdrawal and anhedonia)

A nurse is caring for a client who is taking phenelzine. For which of the following manifestations should the nurse monitor as an adverse effect of this medication? (Select all that apply) A. Elevated blood glucose level B. Orthostatic hypotension C. Priapism D. Hypomania E. Bruxism

1. Orthostatic hypotension 2. Hypomania *An elevated blood glucose is anot an adverse effect of phenelzine *Priapism is an adverse effect of trazodone, rather than phenelzine *Bruxism is an adverse effect of SSRIs, rahter than phenelzine

Which characteristic(s) is/are an example of a negative symptom of schizophrenia? (Select all that apply) A. Avolition B. Hallucination C. Psychomotor retardation D. Delusions E. Anhedonia

1. Avolition 2. Psychomotor retardation 3. Anhedonia *Negative symptoms are abilities or personal characteristics that are absent or lost to the patient

A mother confides in the nurse that she fears her daughter has anorexia nervosa. The nurse is aware that which of the mother's concerns are diagnostic criteria for anorexia nervosa? (Select all that apply.) A. Being 5 feet 9 inches and refusing to weigh more than 100 pounds B. Intense fear of gaining weight, so she runs 10 miles a day C. Not having a menstrual period for 6 months D. Hypersexuality E. Binge eating

1. Being 5 feet 9 inches and refusing to weigh more than 100 pounds 2. Intense fear of gaining weight, so she runs 10 miles a day *Causes for concern related to the diagnostic criteria for anorexia nervosa include intense fear of gaining weight, so she runs 10 miles a day; being 5 feet 9 inches and refusing to weigh more than 100 pounds. Hypersexuality is often associated with mania, and binge eating is associated with bulimia nervosa. The person with anorexia nervosa may have an irregular menstrual cycle but this is not diagnostic for the disease.

A nurse is reinforcing teaching with a group of guardians about manifestations of conduct disorder. Which of the following findings should the nurse include? (select all that apply) A. Bullying of others B. Threats of suicide C. Law-breaking activities D. Nacissistic behavior E. Flat affect

1. Bullying of others 2. Threats of suicide 3. Law-breaking activities *Low self-esteem, rather than narcissism and irritability and temper outbursts, rather than flat affect are expected findings of conduct disorder

The nurse is planning care for a patient with early AD. Interventions for which patient problems are appropriate for this patient's care plan? (Select all that apply.) A. Reduced cardiac output B. Caregiver stress and fatigue C. Nutritional deficiencies D. Pain E. Airway patency issues

1. Caregiver stress and fatigue 2. Nutritional deficiencies *Patients with AD often forget to eat, so they are at risk for altered nutritional status. Caregivers of AD patients are at extreme risk for fatigue and the effects of chronic stress. Pain, airway patency issues, and reduced cardiac output are not problems associated with early AD.

The nurse cautions the recovering alcoholic who is on disulfiram (Antabuse) should avoid even small exposure to alcohol. Which signs and symptoms are characterisitic of a reaction of disulfiram (Antabuse) with alcohol? (Select all that apply) A. Chest pain B. Nausea and vomiting C. Hypertension D. Blurred vision E. Blinding headache

1. Chest pain 2. Nausea and vomiting 3. Blurred vision *Disulfiram (Antabuse) is a drug that causes unpleasant reactions if the patient decides to return to drinking withing 2 weeks after starting Antabuse. Even small quantities of alcohol that might be inhaled from shaving lotion could trigger serious reactions such as chest pain, nausea and vomiting, hypotension, weakness, blurred vision, and confusion

What actions does becoming substance free involve? (select all that apply) A. Committing to a lifestyle change B. Developing new coping skills C. Committing to honesty in communication D. Gaining an awareness of possible periods of relapse E. Completing a program in 12 months

1. Committing to a lifestyle change 2. Developing new coping skills 3. Committing to honesty in communication 4. Gaining an awareness of possible periods of relapse *The limitation of 12 months is not part of the commitment. Rehabilitation may take several years or a lifetime

A nurse is caring for a client who takes paroxetine to treat post traumatic stress disorder. The client states, "I grind my teeth during the night, which causes pain in my mouth." The nurse should identify which of the following interventions as possible measures to manage the client's bruxism? (Select all that apply) A. Concurrent administration of buspirone B. Administration of a different SSRI C. Use of a mouth guard D. Changing to a different class of antianxiety medication E. Increasing the dose of paroxetine

1. Concurrent administration of buspirone 2. Use of a mouth guard 3. Changing to a different class of antianxiety medication *Other SSRIs will also have bruxism as an adverse effect and increasing the dose of paroxetine can cause the adverse effect to worsen; therefore these are not effective measures

A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (Select all that apply) A. Conducting a suicide risk screening on all new clients B. Creating a support group for family members of clients who died by suicide C. Informing high school teens about suicide prevention D. Initiating one-on-one observation for a client who has current suicidal ideation E. Reinforcing teaching middle-school educators about warning indicators of suicide

1. Conducting a suicide risk screening on all new clients 2. Informing high school teens about suicide prevention 3. Reinforcing teaching middle-school educators about warning indicators of suicide *Primary interventions include suicide prevention through the use of screenings to identify individuals at risk and through the use of community education. Conducting a suicide risk screening on all new clients is an example of a primary intervention. Informing high school teens about suicide prevention and reinforcing teaching with middle-school teachers to recognize the warning indicators are examples of primary intervention. *Creating a support group for family members of clients who died by suicide is an example of a tertiary intervention *Initiating one-on-one observation for a client who has current suicidal ideation is an example of a secondary intervention

Which findings indicate that the recovering alcoholic may be developing Wernicke encephalopathy? (Select all that apply) A. Confusion B. Hallucinations C. Verbally aggressive behavior D. Ataxia E. Seizures

1. Confusion 2. Ataxia *A serious effect of chronic alcohol anuse is damage to brain cells. A condition that is reversible with treatment is Wernicke encephalopathy. This condition precedes Kosakoff sundrome (substance-induced persisting dementia), which is irreversible. If the individual has a history of alcohol use and displays the symptoms of confusion, atacia, and significant memory loss, Wernicke encephalopathy is suspected. Verbal aggression, hallucinations, and seizures are not characteristic of Wernicke encephalopathy

What interventions should you use when a patient is becoming progressively louder and more aggressive? (select all that apply) A. Continuously assess for pacing, fidgeting, and increase in verbalizations B. Maintaing a calm, self-assured attitude, even if frightened C. Listen and state, "I care and want to help." D. Move close to the patient to provide reassurance E. Set strict limits on the patient's behavior F. Stand to the side or sideways to present self as a smaller target G. Explain the hospital policy and offer the patient a copy

1. Continuously assess for pacing, fidgeting, and increase in verbalizations 2. Maintaing a calm, self-assured attitude, even if frightened 3. Listen and state, "I care and want to help." 4. Set strict limits on the patient's behavior 5. Stand to the side or sideways to present self as a smaller target *Watch the patient, be calm, listen, project caring, set limits, and protect yourself. (4) Do not move toward the patient; being too close can be perceived as a threat. (7) Explaining hospital policy and offering a copy is too much information at this time.

The nurse is caring for a patient recently diagnosed with AD. The nurse knows this patient's symptoms are caused by which changes in the brain? (Select all that apply.) A. Decreased production of neurotransmitters B. Development of gumma C. Tangled nerve cells D. Neuron loss in frontal and temporal lobes E. Formation of aneurysms

1. Decreased production of neurotransmitters 2. Tangled nerve cells 3. Neuron loss in frontal and temporal lobes *In AD, there is a loss of neurons in the frontal and temporal lobes. The atrophy in these areas accounts for the patient's inability to process and integrate new information and to retrieve memories. Brain biopsies of patients with AD have revealed nerve cells that are tangled and twisted and an abnormal buildup of proteins. Production of neurotransmitters (e.g., acetylcholine, serotonin) is relatively decreased for these patients. Gumma development is associated with syphilis. Aneurysm development is not associated with AD.

A nurse is assisting with planning a group therapy for clients dealing with bereavement. Which of the following activities should the nurse include in the orientation phase? (select all that apply) A. Encourage the group to work toward goals B. Define the purpose of the group C. Discuss termination of the group D. Identify informal roles of members within the group E. Establish an expectation of confidentiality within the group

1. Define the purpose of the group 2. Discuss termination of the group 3. Establish an expectation of confidentiality within the group *During the orientation phasem also known as the initial phase, identify the purpose of the group, discuss termination of the group, and set the tone of the group *During the working phase, the group works toward goals and identify informal roles that other members in the group often assume

The nurse is receiving report on a patient diagnosed with a thought disorder. The nurse should anticipate the patient to exhibit which symptoms or behaviors? (Select all that apply.) A. Delusions B. Dramatic behavior C. Anorexia D. Hallucinations E. Apathy F. Staff splitting

1. Delusions 2. Hallucinations 3. Apathy *The patient with a thought disorder is likely to exhibit apathy, hallucinations, and delusions. Anorexia is associated with depression. Staff splitting and dramatic behavior are associated with personality disorders.

A charge nurse is reviewing Kubler-Ross: Five stages of Grief with a group of newly licensed nurses. Which of the following stages should the charge nurse include in the review? (Select all that apply) A. Disequilibrium B. Denial C. Bargaining D. Anger E. Depression

1. Denial 2. Bargaining 3. Anger 4. Depression *Disequilibrium is the second stage of Bowlby's four stages of grief

A nurse is assisting the guardians of a school-age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following strategies should the nurse recommend? (Select all that apply) A. Allow the child to choose which behaviors are unacceptable B. Use role-playing to act out unacceptable behavior C. Develop a reward system for acceptable behavior D. Encourage the child to participate in school sports E. Be consistent when addressing unacceptable behavior

1. Develop a reward system for acceptable behavior 2. Encourage the child to participate in school sports 3. Be consistent when addressing unacceptable behavior *The guardians should have a method to reward the child for acceptable behavior. Encourage physical activity through which the child can use energy and obtain success, and set clear limits on unacceptable behavior. They should focus on acceptable behavior and demonstrate this through modeling

A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (select all that apply) A. Difficulty concentrating on tasks B. Obsessive need to talk about the traumatic event C. Negative self-image D. Recurring nightmares E. Diminished reflexes

1. Difficulty concentrating on tasks 2. Negative self-image 3. Recurring nightmares *Manifestations of PTSD include the inability to concentrate on or complete tasks, feeling guilty and having a negative self-image, and recurring nightmares or flashbacks *A client who has PTSD is reluctant to talk about the traumatic event that triggered the disorder *A client who has PTSD has an increased startle reflex and hypervigilence

A nurse is assisting with the preparation of a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the nurse include? (Select all that apply) A. Difficulty in getting along with other members of a group B. Belief in the ability to become invisible during times of stress C. Display of defense mechanisms when routines are changed D. Claiming to be more important than other persons E. Difficulty understanding why it is inappropriate to have a personal relationship with staff

1. Difficulty in getting along with other members of a group 2. Display of defense mechanisms when routines are changed 3. Difficulty understanding why it is inappropriate to have a personal relationship with staff *Difficulty with social and professional relationships is a personality characteristic that can be seen with all personality disorder types *Maladaptive responses to stress is a personality characteristic that can be seen in clients who has experiencing personality disorders *Difficulty understanding personal boundaries is a personality characteristic that can be seen with all personality disorder types *Clients who have schizotypal personality disorder can display magical thinking or delusions. However, this is not associated with all personality disorder types *Clients who have narcissistic personality disorder can display gradiose thinking. However, this is not associated with all personality disorder types

A nurse is reinforcing teaching about relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse review? (select all that apply) A. Use caffeine in moderation to prevent relapse B. Difficulty sleeping can indicate a relapse C. Begin taking your medications as soon as a relapse begins D. Participating in psychotherapy can help prevent a relapse E. Anhedonia is a clinical manifestation of a depressive relapse

1. Difficulty sleeping can indicate a relapse 2. Participating in psychotherapy can help prevent a relapse 3. Anhedonia is a clinical manifestation of a depressive relapse *The client who has bipolar disorder should avoid the use of caffeine because it can precipitate a relapse *The client who has bipolar disorder should take prescribed medications to prevent and minimize a relapse

A nurse is collecting data from a client who was recently admitted for treatment of major depressive disorder (MDD). Which of the following findings should the nurse expect the client to report? (Select all that apply) A. Difficulty sleeping for several weeks B. Inability to concentrate on simple tasks C. Desire for sexual activity with multiple partners D. Not bathing for several days E. Lack of enjoyment from a long-time hobby of gardening

1. Difficulty sleeping for several weeks 2. Inability to concentrate on simple tasks 3. Not bathing for several days 4. Lack of enjoyment from a long-time hobby of gardening *The nurse should expect a client who has MDD to report either difficulty sleeping or excessive, indecisiveness and an inability to concentrate, a lack of personal hygiene and self-care, and anhedonia, which is the inability to feel pleasure or happiness from a hobby or activity that once provided these positive feelings

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to reinforce necessary information to the client? (select all that apply) A. Reassure the client that everything will be okay B. Discuss prior use of coping mechanisms with the client C. Ignore the client's anxiety so that she will not be embarrassed D. Demonstrate a calm manner while using simple and clear directions E. Gather information from the client using closed-ended questions

1. Discuss prior use of coping mechanisms with the client 2. Demonstrate a calm manner while using simple and clear directions *Discussing the prior use of coping mechanisms assists the client in identifying ways of effectively coping with the current stressor *Providing a calm presence assists the client in feeling secure and promotes relaxation. Clients experiencing moderate levels of anxiety often benefit from the direction of others *Providing false reassurance is an example of nontherapeutic communication *Recognizing the client's current level of anxiety assists the client to begin the process of problem solving *Using open-ended questions for client communication encourages the client to express feelings and identify the source of the anxiety

Patients who use inhalants and hallucinogens are likely to experience which negative effects? (Select all that apply) A. Distortion of senses B. Intense pruritus C. Uncontrolled flashbacks D. Koilonychia E. Severely impaired judgment

1. Distortion of senses 2. Uncontrolled flashbacks 3. Severely impaired judgment *Hallucinogens cause distortiom of the senses, an inability to separate fact from fantasy, impaired sense of time, and severely impaired judgment. Users never know whether they will have a good "trip" or a bad one. Uncontrolled flashbacks (feelings and sensations associated with use despite being drug-free) can occur. This group of drugs is very dangerous because use is known to cause panic, paranoia, and death from extremely impaired judment. Inhalants and hallucinogens are not known to cause intense itching (pruritus) or spoon-shaped nails (koilonychia)

A nurse is assisting in the discharge planning for a client following alcohol detoxification. The nurse should expect prescriptions to promote long-term abstinence from alcohol? (select all that apply) A. Lorazepam B. Diazepam C. Disulfiram D. Naltrexone E. Acamprosate

1. Disulfiram 2. Naltrexone 3. Acamprosate *Disulfiram promotes abstinence through aversion therapy *Naltrexone promotes abstinene by suppressing the cravig and pleasurable effects of alcohol *Acamprosate decreases the unpleasant effects resulting from abstinence *Lorazepam is prescribed for short-term use during withdrawal *Diazepam is prescribed for short-term use during withdrawal

Which nursing considerations relate to the administration of lithium? (select all that apply) A. Administer the medication on an empty stomach B. Restrict fluids to 1000 mL daily C. Draw frequent blood levels D. Teach the importance of contraception while taking the drug E. Teach the importance of avoiding caffeine while taking this drug

1. Draw frequent blood levels 2. Teach the importance of contraception while taking the drug 3. Teach the importance of avoiding caffeine while taking this drug *Lithium should be taken with food, and fluids should be increased to 3000 mL daily

A nurse is caring for a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom (EPS)? (Select all that apply) A. Decreased level of consciousness B. Drooling C. Involuntary arm movements D. Urinary retention E. Continual pacing

1. Drooling 2. Involuntary arm movements 3. Continual pacing *Decreased LOC is an indication of neuroleptic malignant syndrome rather than an EPS *Urinary retention is an antocholinergic effect rather than an EPS

A nurse is working in a community mental health facility. Which of the following services does this type of program provide? (Select all that apply) A. Educational groups B. Medication dispensing programs C. Individual counseling programs D. Detoxification programs E. Family therapy

1. Educational groups 2. Medication dispensing programs 3. Individual counseling programs 4. Family therapy *Detoxification programs are services provided in a partial hospitilization program

The nurse explains that neuroleptic drugs such as chlorpromazine (Thorazine) are very effective in treating specific symptoms of schizophrenia. Which effect(s) should chlorpromazine have? (Select all that apply) A. Eliminating hallucinations B. Stimulating effective interpersonal relationships C. Enabling organized thought D. Increasing activity level E. Eliminating delusional systems

1. Eliminating hallucinations 2. Enabling organized thought 3. Eliminating delusional systems *Hallucinations, disorganized thought, and delusional systems are the positive symptoms that respond to neuroleptics. Negative symptoms such as withdrawal and inactivity do not respond well to these drugs

The nurse is working on a busy medical-surgical unit. An elderly patient has fallen out of bed twice, despite repeated verbal instructions to call for assistance. What are appropriate interventions to ensure safety? (Select all that apply) A. Encourage family members and friends to stay with the patient B. Obtain an order for an anioxlytic medication C. Keep the patient close to the nurses' station D. Check on the patient frequently to offer nutrition, fluids, pain relief, and toileting E. Place the bed in the lowest position with three side rails up F. Temporarily place restraints and secure knots to the bedrails G. Advise the patient that the hospital is not liable if he refuses to cooperate

1. Encourage family members and friends to stay with the patient 2. Keep the patient close to the nurses' station 3. Check on the patient frequently to offer nutrition, fluids, pain relief, and toileting 4. Place the bed in the lowest position with three side rails up

You identify which patient behavior as indicative of mild Alzheimer disease? (Select all that apply) A. Encourage verbalization of feelings B. Refer the caregiver to respite care or day care programs C. Remind the caregiver to maintain composure D. Assess for alternative family support and resources E. Reassure the caregiver that everything will be okay F. Encourage consideration of admission to a nursing home G. Tell the caregiver to focus on past happy times with the client

1. Encourage verbalization of feelings 2. Refer the caregiver to respite care or day care programs 3. Assess for alternative family support and resources *Encouraging feelings, giving referrals, and assessing for support are useful to the caregiver. (3) Telling the caregiver to calm down or giving false assurance is not therapeutic or a helpful response. (5) Telling the caregiver that everything will be okay is nontherapeutic, as everything will not be okay. (6) Suggesting admission to a nursing home is unsolicited and premature advice. (7) Telling the caregiver to recall happy times is possibly therapeutic if you have time to have a long discussion, but this suggestion may provoke more guilt and shame if there is no follow-up discussion.

What are some common behavioral symptoms related to cannabis use? (Select all that apply.) A. Hallucinations B. Insomnia C. Euphoria D. Increased appetite E. Relaxed inhibitions

1. Euphoria 2. Increased appetite 3. Relaxed inhibitions *Common behavioral symptoms related to cannabis use include euphoria, relaxed inhibitions, increased appetite, and disoriented behavior. Hallucinations are associated with hallucinogens and insomnia is associated with CNS stimulants.

Which criteria must be established to assign a diagnosis of dementia? (Select all that apply) A. Evidence of cognitive deficits B. Evidence of aphasia, apraxia, or agnosia C. Impairment in social function D. Impairments of occupational function E. Neurologic signs and symptoms, such as ataxic gait

1. Evidence of cognitive deficits 2. Evidence of aphasia, apraxia, or agnosia 3. Impairment in social function 4. Impairments of occupational function 5. Neurologic signs and symptoms, such as ataxic gait *Dementia is characterized by several cognitive deficits, memory in particular, and tends to be chronic in nature. It is classified according to etiology (cause or origin of disease). All options are criteria for the diagnosis of dementia

A nurse is performing data collection on a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply) A. Excessive worry for 6 months B. Impulsive decision making C. Delayed reflexes D. Restlessness E. Sleep disturbances

1. Excessive worry for 6 months 2. Restlessness 3. Sleep disturbances *Generalized anxiety disorder is characterized by uncontrollable, excessive worry for more than 6 months, restlessness, and sleep disturbances (the inability to fall asleep), procrastination in decision making, and muscle tension

The nurse is assisting the patient with alcohol use to plan activities that will help him to maintain a healthy lifestyle after he is discharged from the hospital. Which are appropriate actions by the nurse? (select all that apply) A. Remind the patient that the physical symptoms of withdrawal will not last forever B. Help him to make a list of activities that would distract him from the cravings. C. Ask him to contact old drinking buddies to tell them that he has stopped using alcohol D. Encourage him to socialize with an old drinking buddy and talk about happier times E. Encourage him to participate actively and frequently in a 12-step program

1. Help him to make a list of activities that would distract him from the cravings. 2. Encourage him to participate actively and frequently in a 12-step program

Which actions describe diagnostic criteria for the diagnosis of substance abuse? (Select all that apply) A. Failure to meet obligations B. Putting self and others in potential harm C. Experiencing conflict with law enforcement authorities D. Developing physical debilitation E> Denying existence of a problem

1. Failure to meet obligations 2. Putting self and others in potential harm 3. Experiencing conflict with law enforcement authorities *Physical debilitation and denial are not in the criteria established by the American Psychiatric Association for the diagnosis of substance abuse

A nurse is collecting data for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (select all that apply) A. History of gradual memory loss B. Family report of personality changes C. Hallucinations D. Unaltered level of consciousness E. Restlessness

1. Family report of personality changes 2. Hallucinations 3. Restlessness *The client who has delirium can experience rapid personality changes *The client who has delirium can have perceptual disturbances (hallucinations and illusions) *The client who has delirium commonly exhibits restlessness and agitation *The client who has delirium can experience memory loss with sudden rather than gradual onset *The client who has delirium is expected to have an altered level of consciousness that can rapidly fluctuate

A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? (Select all that apply) A. Bradycardia B. Fine tremors of both hands C. Hypotension D. Vomiting E. Restlessness

1. Fine tremors of both hands 2. Vomiting 3. Restlessness *An expected finding of alcohol withdrawal is tachycardia rather than bradycardia *An expected finding of alcohol withdrawal is hypertension rather than hypotension

The nurse is reviewing the medical history of a patient who is being evaluated for anorexia nervosa. Which characteristic(s) would be consistent with the condition? (select all that apply) A. Weight loss of 2 to 3 pounds in the past month B. Binge eating C. Frequent mood changes D. Absence of three consecutive menstrual periods E. Body weight less than 85% of what is expected for height and weight

1. Frequent mood changes 2. Absence of three consecutive menstrual periods 3. Body weight less than 85% of what is expected for height and weight *Anorexia nervosa is characterized by the patient's refusal to maintain minimal body weight or eat adequate quantities of food. There is a disturbance in the perception of body shape and size and an extreme fear of becoming fat. The patient strives for perfection and control by controlling caloric intake. Defining characteristics include frequent mood fluctuation, absence of three consecutive menstrual periods, and body weight less than 85% of what is expected for height and weight

Which psychotic feature(s) is/are characteristic of schizophrenia? (select all that apply) A. Hallucinations B. Sexual dysfunction C. Delusions D. Disorganized speech E. Disorganized behavior

1. Hallucinations 2. Delusions 3. Disorganized speech 4. Disorganized behavior *Sexual dysfunction is not a characteristic of schizophrenia

A nurse is collecting data on a client 4 hr after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the RN and provider as indications of serotonin syndrome? (Select all that apply) A. Hypothermia B. Hallucinations C. Muscular flaccidity D. Diaphoresis E. Agitation

1. Hallucinations 2. Diaphoresis 3. Agitation *Fever, rather than hypothermia and muscle tremors, rather than flaccidity, are indications of serotonin syndrome

The patient has anhedonia, flat affect, illusions, hallucinations, and delusions of persecution. The nurse knows which of this patient's symptoms are most likely to improve with antipsychotic medication? (Select all that apply.) A. Hallucinations B. Flat affect C. Illusions D. Delusions of grandeur E. Anhedonia

1. Hallucinations 2. Illusions 3. Delusions of grandeur *Antipsychotic medications are most effective for positive symptoms, including illusions, hallucinations, and delusions. They are less effective for negative symptoms (flat affect and anhedonia).

Which signs and symptoms are consistent with general anxiety disorder (GAD)? (Select all that apply) A. Heart rate of over 100 beats per minute B. Restlessness C. Urinary retention D. Fatigue E. Muscular tension

1. Heart rate of over 100 beats per minute 2. Restlessness 3. Fatigue 4. Muscular tension *A person who experiences persistent, unrealistic, or excessive worry about two or more life circumstances for 6 months or longer us exhibiting symptoms associated with GAD. GAD usually develops slowly and is chronic in nature. Dieresis rather than urinary retention is commonly seen with GAD.

A nurse is caring for a client who has major depressive disorder. Which of the following should the nurse identify as a risk factor for depression? (Select all that apply) A. Male sex B. History of chronic bronchitis C. Recent death in client's family D. Family history of depression E. Personal history of panic disorder

1. History of chronic bronchitis 2. Recent death in client's family 3. Family history of depression 4. Personal history of panic disorder *Depressive disorders are more common in a client who has a chronic medical condition, are more likely to occur in a client who is experiencing a high amount of stress (when grievin the death of a family member), those who have a family history of depression, and has a history of an anxiety or personality disorder. Females are twice as likely as males to experience a depressive disorder

A nurse is caring for a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? (select all that apply) A. Amenorrhea B. Hypokalemia C. Yellowing of the skin D. Slightly elevated body weight E. Presence of lanugo on the face

1. Hypokalemia 2. Slightly elevated body weight *Amenorrhea, Yellowing of the skin, and presence of lanugo is an expected finding of anorexia rather than bulimia nervosa

Which criteria are part of alcohol dependency diagnosis guidelines? (select all that apply) A. Identifiable withdrawal signs and symptoms B. Decreasing tolerance C. Altered family relationships D. Blackouts or amnesia pertinent to drinking episodes E. Altered occupational productivity

1. Identifiable withdrawal signs and symptoms 2. Altered family relationships 3. Blackouts or amnesia pertinent to drinking episodes 4. Altered occupational productivity *Identifiable withdrawal signs and symptoms, altered family relationships, blackouts or amnesia pertinent to drinking episodes, and altered occupational productivity are all part of the diagnostic guidelines for the diagnosis of alcohol dependency. Increasing tolerance is also part of the diagnostic criteria

A nurse is reinforcing discharge teaching with the partner of a client who has Alzheimer's disease about home safety. Which of the following instructions should the nurse give to the partner to decrease the client's risk for injury? (select all that apply) A. Install extra locks at the top of exit doors B. Place rugs over electrical cords C. Put cleaning supplies on the top of a shelf D. Place the client's mattress on the floor E. Install light fixtures above stairs

1. Install extra locks at the top of exit doors 2. Place the client's mattress on the floor 3. Install light fixtures above stairs *Placing door locks up high where they are difficult to reach can prevent exiting the home and wandering outside *Placing the client's mattress on the floor reduces the risk for falls out of bed *Stairs should have adequate lighting to reduce the risk for falls *Rugs create a fall risk hazard and should be removed. Electrical cords should be secured to baseboards rather than covered *Cleaning supplies with colored tape does not prevent the client's access to hazardous materials

A nurse is working with a client who has recently lost a guardian. The nurse recognizes that which of the following factors influence a client's gried and coping ability? (Select all that apply) A. Interpersonal relationships B. Culture C. Birth order D. Religious beliefs E. Prior experience with loss

1. Interpersonal relationships 2. Culture 3. Religious beliefs 4. Prior experience with loss *Birth order is not a factor that influences grief and ability to cope

The home health nurse assesses caregivers for a person with a cognitive deficit. Which finding(s) is/are characteristic of exhaustion? (select all that apply) A. Irritability with other family members and the patient B. Report of sleep disturbances C. Anger at patient and self D. Depression E. Fatigue

1. Irritability with other family members and the patient 2. Report of sleep disturbances 3. Anger at patient and self 4. Depression 5. Fatigue *All options are characteristics of exhaustion in caregivers to the cognitively impaired

The usage of "bath salts" is a societal problem because it (select all that apply) A. Is illegal in all states under federal law B. Is the most addictive of all abused substances C. Is easily obtained over the internet and in many stores D. Potentially causes violence, paranoia, and suicide E. Causes lung cancer if smoked excessively

1. Is the most addictive of all abused substances 2. Is easily obtained over the internet and in many stores 3. Potentially causes violence, paranoia, and suicide *These drugs are the most addictive of any recreational drug. They are easily obtained on the internet and at head shops and other places. "Bath salts" potentially cause the patient to become violent, paranoid, and/or suicidal. (1) "Bath salts" are not illegal yet. (5) Use of bath salts can increase cancer risk but does not specifically cause lung cancer

The nurse is teaching the patient about lithium carbonate. What information is appropriate to include in the teaching? (Select all that apply) A. It takes 3-4 days to reach therapeutic levels B. It helps decrease the manic behavior C. There is a small margin of safety between a therapeutic level and a toxic level D. Maintain salt intake and drink adequate fluids; salt depletion may cause toxicity E. Take the medication on an empty stomach F. Do not become dehydrated

1. It helps decrease the manic behavior 2. There is a small margin of safety between a therapeutic level and a toxic level 3. Maintain salt intake and drink adequate fluids; salt depletion may cause toxicity 4. Do not become dehydrated

A nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following tasks should the nurse include in the discussion? (Select all that apply) A. The needs of both partipants are met B. An emotional commitment exists between the participants C. It is goal-directed D. Behavioral change is encouraged E. A termination date is established

1. It is goal-directed 2. Behavioral change is encouraged 3. A termination date is established *A therapeutic nurse-client relationship is goal oriented, encourages positive behavioral changes, has an established termination date, and focuses on the needs of the client. An emotional commitment between the particpants is characteristic of an intimate or social relationship rather than one that is therapeutic

Milieu therapy is a therapeutic application for people with personality disorders. What principle(s) underscore(s) the basis of this method? (Select all that apply) A. Maintaining a structured environment B. Participating as a member of the structured environment C. Practicing appropriate social behavior D. Actively attempting to modify behavior E. Learning to modify feelings and emotional responses

1. Maintaining a structured environment 2. Participating as a member of the structured environment 3. Practicing appropriate social behavior 4. Actively attempting to modify behavior 5. Learning to modify feelings and emotional responses *Milieu therapy provides all these options for treating people with personality disorders

Which characteristic(s) of personality disorders should the nurse consider? (select all that apply) A. Impaired cognition B. Maladaptive response to life's events C. Inability to maintain relationships D. Poor impulse control E. Inappropriate emotional responses

1. Maladaptive response to life's events 2. Inability to maintain relationships 3. Poor impulse control 4. Inappropriate emotional responses *There is no impaired cognition in the individual with a personality disorder

Alzheimer disease has a greater impact on society than delirium because (select all that apply) A. Memory deficits become progressive B. It often improves with correction of the underlying cause C. It causes mental decline and the need for ongoing, more involved care D. The expense of care for dementia patients is a drain on society and families E. A family member may have to leave the workforce to care for the patient

1. Memory deficits become progressive 2. It causes mental decline and the need for ongoing, more involved care 3. The expense of care for dementia patients is a drain on society and families 4. A family member may have to leave the workforce to care for the patient *With Alzheimer disease, memory deficits are progressive. Mental decline and the need for more and more care increase as the disease progresses. The expense of caring for an Alzheimer patient is a drain on families and society. A family member may have to leave the workforce and stay home to care for a relative with Alzheimer disease. (2) Delirium often improves with the correction of the underlying cause.

A nurse is collecting data from a client following an ECT procedure. Which of the following findings should the nurse expect? (Select all that apply) A. Hypotension B. Paralytic ileus C. Memory loss D. Polyuria E. Confusion

1. Memory loss 2. Confusion *Transient short-term memory loss and confusion is an expected finding immediately following ECT *Following ECT, the client's blood pressure is expected to be elevated *Paralytic ileus and polyuria are not an expected findings of ECT

Which strategy/strategies best benefit(s) a late-stage Alzheimer patient with global amnesia? (select all that apply) A. Reorientation sessions B. Music therapy C. Reminiscence therapy D. Pet therapy E. Looking at family scrapbooks

1. Music therapy 2. Pet therapy *Global amnesia wipes out all memory. Orientation and family pictures will not be helpful. Activities that stimulate the senses, such as music, stroking an animal, or aroma therapy, can be pleasing

A nurse is assisting with planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse recommend for inclusion in the plan of care? (Select all that apply) A. Provide flexible client behavior expectations B. Offer concise explanations C. Establish consistent limits D. Disregard client concerns E. Use a firm approach with communication

1. Offer concise explanations 2. Establish consistent limits 3. Use a firm approach with communication *Offering concise explanations improves the client's ability to focus and comprehend the information *Establishing consistent limits decreases the risk for client manipulation *Using a firm approach with client communication promotes structure and minimizes inappropriate client behaviors *Establish consistent behavior expectations to decrease the risk for client manipulation *Repond to valid client concerns to foster a trusing nurse-client relationship

What trusting nursing interventions are appropriate when a patient demonstrates negative symptoms of apathy, social isolation, and lack of motivation? (Select all that apply) A. Offer self and be available B. Reorient to person, place, and time C. Keep all promises D. Invite the patient to join groups E. Leave the door open for future interactions F. Encourage independence in ADLs

1. Offer self and be available 2. Keep all promises 3. Invite the patient to join groups 4. Leave the door open for future interactions *Offering self, keeping promises, suggesting socialization, and planning future interactions are interpersonal ways to build trust. (2) Reorienting to person, place, and time is useful when the patient is confused or has a cognitive disorder such as delirium. (6) Encouraging independence in ADLs is a good general measure but not a first-line intervention for establishing trust.

A nurse is caring for a client who takes ziprasidone. The client reports difficulty swallowing the oral medication and becomes extremely agitated with injectable administration. The nurse should contact the provider to request a change to which of the following medications? (select all that apply) A. Olanzapine B. Quetiapine C. Aripriprazole D. Clozapine E. Asenapine

1. Olanzapine 2. Aripriprazole 3. Clozapine 4. Asenapine *Quetiapine is available only in tablets or extended-release tablets and will therefore not address the current concerns with medication administration. The other medications areavailable in an orally disintegrating appropriate for clients who have difficulty swallowing tablets. This route also decreases the risk for agitation associated with an injection.

What does the Mini-Mental Status Exam (MMSE) assess? (select all that apply) A. Orientation B, Judgment C. Memory D. Insight E. Ability to follow directions

1. Orientation 2. Memory 3. Ability to follow directions *The Mini-Mental Status Exam (MMSE) is a popular shortened version of the mental status examination that was developed by Folstein and colleagues in 1975. It can be used for patients who have cognitive disorders or thought disorders to assess orientation, memory, and ability to follow commands. It consists of 11 easily scored items and should take about 5 to 10 minutes to administer. The MMSE does not measure insight or judgment

Which caracteristic(s) increase(s) the probability of suicidal ideations in a depressed patient? (select all that apply) A. Owning a gun collection B. Living with wife and three children C. Being an active member of the local church D. Having a plan to shoot himself in a motel E. Having a brother that recently committed suicide

1. Owning a gun collection 2. Having a plan to shoot himself in a motel 3. Having a brother that recently committed suicide *Suicidal risk increases if the patient has a plan, access to a weapon, and a recent loss

A patient has nightmares and thinks constantly about the sexual assault she experienced. She is seen constantly washing her hands, takes at least four showers a day, and does not go out with friends now because she is constantly cleaning her apartment. What disorders are most related to the symptoms she is experiencing? (Select all that apply.) A. PTSD B. Bipolar disorder C. Mild anxiety D. Generalized anxiety disorder E. Obsessive-compulsive disorder (OCD)

1. PTSD 2. Obsessive-compulsive disorder (OCD) *The symptoms this person is experiencing are related to PTSD and OCD. Mild anxiety increases alertness, motivation, and attentiveness and is not what she is experiencing. Bipolar disorder is a mood disorder. Generalized anxiety disorder is associated with a person who experiences persistent, unrealistic, or excessive worry about two or more life circumstances for 6 months or longer.

A nurse is collecting data on a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is experiencing prodromal syndrome? (select all that apply) A. Lethargy B. Pacing C. Orientation D. Facial grimacing E. Agitation

1. Pacing 2. Facial grimacing 3. Agitation *Lethargy is more likely to be observed in a client who has depression *Disorientation is more likely to be found in a client who has a cognitive disorder

A nurse is caring for a client who is experiencing a crisis. Which of the following medications should the nurse plan to administer? (select all that apply) A. Lithium carbonate B. Paroxetine C. Risperidone D. Haloperidol E. Lorazepam

1. Paroxetine 2. Lorazepam *SSRI antidepressants (paroxetine) can be prescribed to decrease the anxiety and depression of a client who is experiencing a crisis *Benzodiazepines (lorazepam) can be prescribed to decrease the anxiety of a client who is experiencing a crisis *Mood stabililizers (lithium carbonate) are prescribed for bipolar disorder *Antipsychotic medications (risperidone and haloperidol) can be prescribed for disturbed thought processes, usually when accompanied by other psychotic manifestations (hallucinations, delusions, blunt affect)

Which interventions will you teach to the caregivers of a patient with Alzheimer disease? (select all that apply) A. Place door locks up high on the doors B. Redirect to another activity when the patient becomes confused C. Keep lights low in the evening to decrease stimulation D. Offer finger foods to increase caloric intake when restless E. Provide lively activity in the late afternoon to prevent sundown syndrome F. Use clothing with Velcro or other easy fasteners

1. Place door locks up high on the doors 2. Redirect to another activity when the patient becomes confused 3. Offer finger foods to increase caloric intake when restless 4. Use clothing with Velcro or other easy fasteners *Placing door locks up high on the doors prevents the patient from opening doors easily. When a patient with dementia becomes obstinate, redirecting to another place or task is helpful. Giving finger foods increases caloric intake when the patient will not settle long enough to eat at a table. Clothing with Velcro fasteners makes it easier for the patient with dementia to dress. (3) Low lights in the evening may cause sundown syndrome. (5) Lively activity in the afternoon can lead to agitation and exhaustion, triggering sundowning.

A patient who is disheveled and disinterested in hygiene reports overwhelming feelings of sadness and loss of energy. Which nursing interventions are appropriate? (Select all that apply) A. Explain the importance of hygiene to health and appearance B. Encourage the patient to "look good and feel good." C. Plan extra time to help the patient complete hygiene ADLs D. Instruct the nursing assistant to do partial hygiene E. Encourage participation in performing ADLs F. Do everything for the patient until they have recovered G. Have the same caregiver assist daily if possible

1. Plan extra time to help the patient complete hygiene ADLs 2. Instruct the nursing assistant to do partial hygiene 3. Encourage participation in performing ADLs 4. Have the same caregiver assist daily if possible *Allowing for extra time, practicing partial hygiene (washing face, brushing teeth), and having the same caregiver will help the patient gradually resume self-care. In addition, the patient should be expected to do something for themself even if the action is very limited in the beginning (e.g., holds the washcloth), and the nurse must set the expectation that they will help as much as possible. (1) Explaining the importance of hygiene or trying to point out the relationship of appearance and feelings is not appropriate when the patient is deeply depressed. (2) Encouraging the patient to "look good and feel good" is not appropriate at this time. They do not need a pep talk. (6) Doing everything for a patient is never the best option unless the patient is unable to do anything for themself (comatose or catatonic).

A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations in the discussion? (Select all that apply) A. Constipation B. Polyruria C. Rash D. Muscle weakness E. Tinnitus

1. Polyruria 2. Muscle weakness *Diarrhea, rather than constipation, is an early indication of lithium toxicity *A rash is not indicated of lithium toxicity *Tinnitus is an indication of severe, rather than early, toxicity

A nurse is assisting with planning cognitive reframing techniques for a client who has an anxiety disorder. Which of the following techniques should the nurse recommend to include in the plan of care? (Select all that apply) A. Priority restructering B. Monitoring thoughts C. Diaphragmatic breathing D. Journal keeping E. Meditation

1. Priority restructering 2. Monitoring thoughts 3. Journal keeping *Diaphragmatic breathing is a form of behavioral reframing technique *Meditation is a form of behavioral therapy rather than a cognitive reframing technique

Which signs and symptoms characterize a major depressive disorder? (select all that apply) A. Eurphora B. Psychomotor retardation C. Indecisiveness D. Sleep disturbances E. Suicidal ideation

1. Psychomotor retardation 2. Indecisiveness 3. Sleep disturbances 4. Suicidal ideation *Major depressive disorder is diagnosed when at least five symptoms characteristic of depression have been present for at least 2 weeks. These symptoms include an overwhelming feeling of sadness; inability to feel pleasure or experience interest in daily activities; weight gain or loss not attributed to dieting; sleep disturbances; fatigue or loss of energy; feelings of worthlessness; difficulty in making decisions or concentrating; and suicidal thoughts

A nurse is preparing to collect data from an infant. Which of the following is an expected finding of shaken baby syndrome? (select all that apply) A. Sunken fontanels B. Respiratory distress C. Retinal hemorrhage D. Altered level of consciousness E. Increase in head circumference

1. Respiratory distress 2. Retinal hemorrhage 3. Altered level of consciousness 4. Increase in head circumference *Bulging, rather than sunken, fontanels are an expected finding of shaken baby syndrome

A nurse is collecting data from a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse? (select all that apply) A. Abrasions on knees B. Round burn marks on forearms C. Mismatched clothing D. Abdominal rebound tenderness E. Areas of ecchymosis on torso

1. Round burn marks on forearms 2. Areas of ecchymosis on torso *Minor injuries (abrasions) on the arms and legs are common in this age group *Mismatched clothing is consistent with the child's need for independence at this age *Abdominal rebound tenderness is a possible indication of appendicitis rather than abuse

The nurse is caring for a patient with memory deficits. The patient asks the nurse about foods that may help improve memory. Which food(s) is/are linked to enhance memory? (select all that apply) A. Salmon B. Red meat C. Pork loin D. Leafy green vegetables E. Fruit

1. Salmon 2. Leafy green vegetables 3. Fruit *Studies show that fish and omega3 polyunsaturated fats, fruits and vegetables, curcumin (curry spice), and the traditional Mediterranean diet may lower the risk of cognitive function and/or Alzheimer disease (AD).

A nurse is reinforcing teaching with the parents of a child who has autism spectrum disorder and a new prescription for imipramine about indications of toxicity. Which of the the following should the nurse include? (select all that apply) A. Seizures B. Agitations C. Photophobia D. Dry mouth E. Irregular pulse

1. Seizures 2. Agitations 3. Irregular pulse *Photophobia and dry mouth are an anticholinergic effect rather than an indication of TCA toxicity

A nurse is caring for a client following the loss of a partner due to a terminal illness. Identify the sequence of Engel's five stages of grief that the nurse should expect the client to experience A. Developing awareness B. Restitution C. Shock and disbelief D. Recovery E. Resolution of the loss

1. Shock and disbelief (the client experiences a sense of numbness and denial over the loss) 2. Developing awareness (the client becomes aware of the reality of the loss resulting in intense feelings of gried. This begins withing hours of the loss) 3. Restitution (The client carries out cultural/religious rituals {a funeral} following the loss) 4. Resolution (The client is preoccupied with the loss. This preoccupation gradually decreases over about a 12-month period) 5. Recovery (The client moves past the preoccupation with the loss and moves forward with life.)

A nurse is reinforcing discharge teaching with the guardians of an adolescent who has bipolar disorder. Which of the following manifestations should the nurse identify as an indication of acute mania? (select all that apply) A. Complete school projects B. Naps during the daytime C. Eats large amounts D. Spends excessive amounts of money E. Speaks using a loud and crass voice

1. Spends excessive amounts of money 2. Speaks using a loud and crass voice *A client who has acute mania is impulsive and at risk of spending excessive amounts of money despite financial status. Additionally, a client who has acute mania has rapid speech and quick thoughts; other alterations in speech include speech that is vulgar or sexually explicit

A nurse is collecting data during the admission of an adolescent client who has depression. Which of the following findings should the nurse expect? (select all that apply) A. Fear of being alone B. Substance use C. Weight gain D. Irritability E. Aggressiveness

1. Substance use 2. Irritability 3. Aggressiveness *solitary play or work, rather than the fear of being alone and Loss of weight and appetite, not weight gain are expected findings associated with depression

In what ways do support groups benefit substance abusers? (select all that apply) A. Support groups provide healthy relationships B. Support groups offer opportunities to practice new coping skills C. Support groups decrease stress and anxiety D. Support groups improve social skills E. Provide cathartic opportunities

1. Support groups provide healthy relationships 2. Support groups offer opportunities to practice new coping skills 3. Support groups decrease stress and anxiety 4. Support groups improve social skills 5. Provide cathartic opportunities *All options are benefits of support groups

A nurse is assisting with a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse recommend to help prevent developing a trauma-related disorder? (Select all that apply) A. Avoid thinking about the incident when it is over B. Take breaks during the incident for food and water C. Debrief with others following the incident D. Avoid displays of emotion in the days following the incident E. Take advantage of offered counseling

1. Take breaks during the incident for food and water 2. Debrief with others following the incident 3. Take advantage of offered counseling *Thinking and talking about a traumatic incident can help prevent development of a trauma-related disorder *Displaying emotions following a traumatic incident can help prevent development of a trauma-related disorder

Postmortem brain examinations of Alzheimer disease (AD) patients reveal which type of finding(s) (select all that apply) A. Tangled nerve cells B. Abnormal buildup of proteins C. Hemorrhagic areas D. Occluded cerebral vessels E. Reduced white matter

1. Tangled nerve cells 2. Abnormal buildup of proteins *Tangled nerve cells and abnormal buildup of protein in the brain have been found on postmortem brain examination of people who have AD

A nurse is assisting with a peer group discussion about the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Which of the following information should the nurse include in the discussion? (select all that apply) A. The DSM-5 includes client education handouts for mental health disorders B. The DSM-5 establishes diagnostic criteria for individual mental health disorders C. The DSM-5 indicates recommended pharmacological treatment for mental health disorders D. The DSM-5 assists nurses in planning care for client's who have mental health disorders E. The DSM-5 indicares expected data collection findings of mental health disorders

1. The DSM-5 establishes diagnostic criteria for individual mental health disorders 2. The DSM-5 assists nurses in planning care for client's who have mental health disorders 3. The DSM-5 indicares expected data collection findings of mental health disorders *The DSM-5 is used by mental health professionals. However, it does not include client education handouts *The DSM-5 does not indicate pharmacological treatment for mental health disorders

A nurse is contributing to the plan of care for a client following surgical implantation of a VNS device. The nurse should plan to monitor for which of the following adverse effects? (Select all that apply) A. Voice changes B. Seizure activity C. Disorientation D. Cough E. Neck pain

1. Voice changes 2 Cough 3. Neck pain *Voice changes are a common advser effect of VNS due to the proximity of the implanted lead on the vagus nerve to the larynx and Pharynx. Coughing is a potential adverse effect of VNS. Neck pain is a potential adverse effect of VNS. However, this usually subsides with time *Seizure activity and disorientation is associated with ECT rather than VNS.

A nurse is reinforcing teaching to a client who has a new prescription for imipramine how to minimize anticholinergic effects. Which of the following instructions should the nurse include in the teaching? (select all that apply) A. Void just before taking the medication B. Increase the dietary intake of potassium C. Wear sunglasses when outside D. Change positions slowly when getting up E. Chew sugarless gum

1. Void just before taking the medication 2. Wear sunglasses when outside 3. Chew sugarless gum *Voiding minimizies urinary hesitancy or retention, sunglasses minimizes the effect of photophobia, and chewing sugarless gum minimizes the effect of dry mouth. orthostatic hypotension is not an anticholinergic effect and the client's potassium level is not effected with imipramine

A nurse is reinforcing teaching with an adolescent client who is to begin taking atomoxetine for ADHD. The nurse should instruct the client to monitor for which of the following adverse effects? A. Somnolence B. Yellowing skin C. Increased appetite D. Fever E. Malaise

1. Yellowing skin 2. Fever 3. Malaise *Yellowing skin, fever, and malaise is a potential indication of hepatotoxicity that the client should report to the provider *Insomnia, rather than somnolence, is an adverse effect that the client should report to the provider *Decreased appetite with resulting weight loss, rather than an increased appetite is a potential adverse effect that the client should report to the provider

The patient is admitted for anorexia nervosa. Which behaviors are most associated with this disorder? (select all that apply) A. shifts food around the plate B. Collects recipes C. Makes elaborate meals for others D. Has superstitions about food E. Uses laxatives and vomits in secret F. Practices excessive exercise

1. shifts food around the plate 2. Collects recipes 3. Makes elaborate meals for others 4. Has superstitions about food 5. Practices excessive exercise

A nurse is collecting data for a client who has illness anxiety disorder. Which of the following are expected for this disorder? (select all that apply) A. Obsessive thoughts about disease B. History of childhood abuse C. Avoidance of health care providers D. Depressive disorder E. Narcisstic disorder

1A. Obsessive thoughts about disease 2. History of childhood abuse 3. Avoidance of health care providers 4. Depressive disorder *Low self-esteem is an expected finidng in a client who has illness anxiety disorder

A nurse is preparing to administer lurasidone 80 mg PO daily to a client. Lurasidone is available as 40 mg tablets. How many tablets should the nurse administer?

2 tablets

A nurse is preparing to administer valproic acid 125 mg PO twice daily to a client. Valproic acid 250 mg/5 mL oral suspension is available. How many mL should the nurse administer per dose? (round to nearest tenth)

2.5 mL/dose

Which percentage of the population that is 85 years of age and older and has some stage of Alzheimer's disease (AD)? A. 10% B. 20% C. 33% D. 50%

33% *AD is the most common degenerative disease of the brain. Approximately 5.7 million Americans have AD and there is no known cause or cure. AD typically affects people over 65 years of age, but can also strike younger people. The 85 year old and over age group is currently the fastest growing age group in the United States. It is estimated that 1/3 of this age group have AD

You are caring for four patients with major depressive disorder. Which patient do you identify as at highest risk for suicide? A. 23-year-old African American female B. 37-year-old Hispanic male C. 42-year-old Asian American female D. 57-year-old Caucasian male

57-year-old Caucasian male *Statistically, older adult white men are more likely to have suicide completion than any other demographic. (1, 2, 4) All of the other patients may attempt or complete suicide but they are not at the highest risk.

Early symptoms of alcohol withdrawal (anxiety, irritability, and agitation) may manifest as early as A. 1-2 hours after the last drink B. 6-12 hours after the last drink C. 24-48 hours after the last drink D. 2-3 days after the last drink

6-12 hours after the last drink

How long does it take the body to metabolize a single can of beer? A. 20 minutes B. 30 minutes C. 40 minutes D. 60 minutes

60 minutes *The metabolization of any amount of alcohol take approximately 1 h

A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? A. A client who has schizophrenia with delusions of grandeur B. A client who has manifestations of depression and attempted suicide a year ago C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod D. A client who has bipolar disorder and paces quickly around the room while talking to themselves

A client who has borderline personality disorder and assaulted a homeless man with a metal rod *A client who is in current danger to self or others is a candidate for a temporary emergency admission

A nurse in a community mental health facility is caring for a group of clients. Which of the following clients should the nurse identify as experiencing an adventitious crisis? A. A client who has a new diagnosis of severe bipolar disorder B. A client who is depressed following a devastating fire in her home C. A client who is experiencing acute grief following his father's death D. A client who is experiencing postpartum depression following the birth of her first child

A client who is depressed following a devastating fire in her home *The nurse should identify that a client who is experiencing depression following a house fire is experiencing an adventitious crisis. An adventitious crisis is unplanned and not a part of everyday life. The crisis can result from a natural disaster, a national disaster, or a crime of violence

A nurse is caring for 4 clients in a community mental health facility. For which of the following clients should the nurse provide a tertiary care intervention? A. A client who has generalized anxiety disorder and reports increased anxiety and insomnia B. A client who is expressing hopelessness during a crisis C. A client who is recovering from a crisis and asks for help in completing the recovery process D. A client who is having difficulty coping with stress and wants to learn relaxation techniques

A client who is recovering from a crisis and asks for help in completing the recovery process *This client should receive tertiary care interventions such as a referral to community groups or facilities to complete recovery from a crisis. Tertiary care is designed to provide support for mental and physical healing after a crisis occurs

A nurse is assisting with caring for a group of clients. Which of the following clients should a nurse consider recommending for referral to an assertive community treatement (ACT) group? A. A client in an acute mental health facility who has fallen several times while running down the hallway B. A client who lives at home and keeps "forgetting" to come in for a scheduled monthly antipsychotic injection for schizophrenia C. A client in a day treatment program who reports increasing anxiety during group therapy D. A client in a weekly grief support who reports still missing a deceased partner who has been dead for 3 months

A client who lives at home and keeps "forgetting" to come in for a scheduled monthly antipsychotic injection for schizophrenia *An ACT group works with clients who are nonadherent with traditional therapy (the client in a home setting who keep "forgetting" a scheduled injection). *A client in acute care who has been running and falling should be helped by the treatment team on the client's unit *A client who has anxiety might be referred to a counseler or mental health provider *A client who is grieving for a deceased partner who die 3 months ago is currently involved in an appropriate intervention

A nurse is assisting with planning care for several clients who are attending community-based mental health programs. Which of the following clients should the nurse collect data from first? A. A client who received a burn on the arm while using a hot iron at home B. A client who requests a change of antipsychotic medication due to some new adverse effects C. A client who reports hearing a voice saying that life is not worth living anymore D. A client who tells the nurse about experiencing manifestations of severe anxiety before and during a job interview

A client who reports hearing a voice saying that life is not worth living anymore *A client who hears a voice saying this is not worth living anymore is at greatest risk for self-harm, and the nurse should collect data from this client first *(A) This client has needs that should be met, but there is another client whom the nurse should collect data from first *(B) This client has needs that should be met, but there is another client who the nurse should collect data from first *(C) This client has needs that should be met, but there is another client whom the nurse should collect data from first

A nurse on a mental health unit is caring for a group of clients. Which of the following is an example of a client using the defense mechanism of rationalization? A. A client who take opioids several times daily but refuses to admit she has a substance use disorder B. A client who bullies her partner because she is ridiculed at work C. A client who was physically abused as a child and cannot remember the events D. A client who states he drinks alcohol to excess because his marriage is failing

A client who states he drinks alcohol to excess because his marriage is failing *This is an example of the defense mechanism of rationalization

Which statement accurately explains the difference between an enabler and a codependent? A. A codependent covers up the substance abuser's behavior B. A codependent rationalizes the substance abuser's behavior C. An enabler uses the substance abuser's behavior to build up his or her own self-esteem D. An enabler is also a substance abuser

A codependent covers up the substance abuser's behavior *The codependent "fixes" things by overcompensating to prevent the abuser from facing reality. Enabling refers to "helping" a person so that the person's consequences from unhealthy behavior are less severe; thus enabling "helps" the unhealthy behavior to continue

What thought process underscores a patient's anorexia nervosa? A. A desire to be attractive by staying slender B. A desire to be involved with food preparation of food, but not eating it C. A desire to punish self by denial of adequate nutrition D. A desire to gain a sense of control by limiting food intake

A desire to gain a sense of control by limiting food intake *Anorexia nervosa is characterized by the patient's refusal to maintain minimal body weight or eat adequate quantities of food. There is a disturbance in the perception of body shape and size and an extreme fear of becoming fat. The patient strives for perfection and control by controlling calorie intake. The person with anorexia nervosa gains a sense of control by limiting food intake

A patient is admitted to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing this patient's record, the nurse would expect to find which report? A. Below-average intelligence B. A history of consistent employment C. Expression of remorse for his actions D. A history of domestic violence

A history of domestic violence *Persons with antisocial disorder lack empathy and exhibit disregard for, and violation of, the rights of others. A tendency toward domestic violence would not be unusual for a person with antisocial personality disorder. Patients with antisocial personality disorder generally have a higher than average intelligence quotient (IQ). Patients with this diagnosis typically lack guilt or remorse for wrongdoing.

A nurse is working with an established group and identifies various member roles. Which of the following should the nurse identify as an individual role? A. A member who praise input from other members B. A member who follows the direction of other members C. A member who brags about accomplishments D. A member who evaluates the group's performance toward a standard

A member who brags about accomplishments *An individual who brags about accomplishments is acting in an individual role that does not promote the progression of the group toward meeting goals *An individual who praises the input of others is acting in a maintenance role *An individual who is a follower is acting in a maintenance role *An individual who evaluates the group's performance is acting in a task role

A nurse is assisting in conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? A. A client's verbal threat to oneself is attention-seeking behavior B. Interventions are ineffective for clients who really want to commit suicide C. Using the term suicide increases the client's risk for a suicide attempt D. A no-suicide contract decreases the client's risk for suicide

A no-suicide contract decreases the client's risk for suicide *A no-suicide contract decreases the client's risk for suicide by promoting and maintaining trust between the nurse and the client. However, it should not replace other suicide prevention strategies *It a a myth that a threat or attempt to kill oneself is attention-seeking behavior, that interventions are ineffective for clients who really want to commit suicide (suicide precautions are shown to be effective in reducing the risk of a death by suicide), and that using the term suicide increases the client's risk for a suicide attempt (discuss suicide openly with the client).

Which response to anxiety is cause for concern? A. A nursing student stays up most of the night to study for an upcoming examination. B. A woman takes several deep breaths before going into the grocery store because shopping makes her nervous. C. A pilot has a small alcoholic drink before his scheduled flight. D. A man asks several of his friends for opinions before asking a woman out on a date.

A pilot has a small alcoholic drink before his scheduled flight. *Ingesting alcohol before a flight is likely to impair the pilot's judgment and put the pilot and others at high risk for injury. Staying up all night to study, asking several friends for opinions before asking a woman on a date, and taking deep breaths before doing something that causes anxiety are appropriate responses to anxiety.

Which social situation most strongly indicates that a recovering alcoholic needs to be advise to call his Alcoholics Anonymous sponsor? A. There is an after-work get-together where alcohol will be served B. A friend is getting married and the toasting will be done with champagne C. A weekend hunting trip with friends will include beer and other liquors D. A niece is having a birthday party and her father always drinks

A weekend hunting trip with friends will include beer and other liquors

A nurse is discussing routine follow-up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following laboratory tests? A. AST/ALT and LDH B. Creatinine and BUN C. WBC and granulocyte counts D. Blood sodium and potassium

AST/ALT and LDH *Routine monitoring of liver function tests is necessary due to the risk for hepatotoxicity *Baseline levels can be drawn. However, routine monitoring of creatinine and BUN, WBC and granulocyte counts, blood sodium and potassium is not necessary

A nurse is collecting data from a client who has binge-eating disorder. Which of the following findings should the nurse expect? A. Amenorrhea B. Abdominal pain C. Restricted caloric intake D. Frequent use of laxatives

Abdominal pain *The nurse should expect the client who has binge-eating disorder to report problems with abdominal pain. This is due to the gastrointestinal dilation that occurs as a result of eating excessive volumes of food

A nurse is caring for a client who has tardive dyskinesia. Which of the following tools should the nurse use in performing an assessment on the client? A. CAGE Assessment B. Hamilton Anxiety Rating Scale C. Abnormal Involuntary Movement Scale (AIMS) D. SAFE-T Tool

Abnormal Involuntary Movement Scale (AIMS) *The AIMS is an assessment tool that identifies and tracks involuntary movements in clients who have tardive dyskinesia

Uses psychoactive drugs in nontherapeutic manner A. Abuse B. Psychological dependence C. Addiction D. Tolerance E. Withdrawal

Abuse

Needs substance to prevent symptoms of withdrawal A. Abuse B. Psychological dependence C. Addiction D. Tolerance E. Withdrawal

Addiction

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) to treat major depression. Following the procedure, which of the following actions should the nurse take? A. Administer oxygen B. Administer an anticonvulsant C. Administer an opioid antagonist D. Administer IV fluids

Administer oxygen *In preparation for ECT, the anesthesiologist administers succinylcholine, which paralyzes respiratory muscles. Clients require oxygen administration until their respiratory status is stable

A nurse is caring for a client who has an alcohol use disorder and is currently undergoing alcohol detoxification. Which of the following interventions should the nurse provide at this time? A. Administer substitution therapy medications B. Teach the client the physical symptoms of withdrawal C. Provide the client with information about a 12 step program D. Identify the causes of the client's alcohol use disorder

Administer substitution therapy medications *During alcohol detoxification, the nurse should provide substitution therapy prescribed by the provider to ease the symptoms of withdrawal

A nurse in a mental health clinic is collecting data from an older adult client who is tearful and reports sleep disturbances. The client tells the nurse, "All of my friends have died, and my children are too busy for me." Which of the following actions should the nurse take first? A. Contact the client's family for support B. Administer the Geriatric Depression Scale C. Refer the client to his provider for an antidepressant medication D. Encourage the client to join a senior support group

Administer the Geriatric Depression Scale *The first action the nurse should take using the nursing process is to assess the client by administering the Geriatric Depression Scale to determine if he is clinically depressed and, if so, assess the severity of the depression. This assessment will allow the nurse to understand the particular needs of the client

A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. Which of the following actions should the nurse take? A. Monitor the client's liver function while taking this medication B. Increase the dosage of the medication every 72 hours C. Offer the client a PRN aspirin while taking the medication D. Administer the medication at bedtime

Administer the medication at bedtime *Donepezil is used to treat the manifestations of mild to moderate Alzheimer's disease. The nurse should administer this medication at bedtime to reduce the risk of injury due to bradycardia

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the client's lithium blood level is 1.2 mEq/L. Which of the following actions should the nurse take? A. Administrer the next dose of lithium carbonate as scheduled B. Prepare for administration of aminophylline C. Notify the provider for a possible increase in the dosage of lithium carbonate D. Request a stat repeat of the client's lithium blood level

Administrer the next dose of lithium carbonate as scheduled *During a manic episode, the lithium blood level should be 0.8 to 1.4 mEq/L. It is appropriate to administer the next dose as scheduled *Aminophylline can be prescribed for treatment of severe toxicity for levels greater than 1.5 mEq/L *A dosage increase would place the client at risk for toxicity and is therefore not and appropriate action *A lithium level of 1.2 mEq/L is an expected finding for a client who is experiencing a manic episode. It is not necessary to request a stat repeat of the lab test

A nurse is caring for an adult client who has injuries resulting from partner violence to law enforcement authorities. Which of the following nursing actions is the highest priority? A. Advise the client about the location of safe houses and shelters B. Encourage the client to participate in a support group for survivors of abuse C. Implement case management to coordinate community and social services D. Educate the client about the use of stress management techniques

Advise the client about the location of safe houses and shelters *The greatest risk to this client is injury from further abuse; therefore, the priority action is to assist the client with the development of a safety plan that includes the identification of safe places to live

The nurse believes that another nurse is "stealing" narcotic doses from patients and self-injecting the medication. What should the nurse do first? A. Follow the nurse to verify suspicions B. Confront the nurse and ask for an explanation C. Ask the nurse if they are getting pain relief D. Ask a supervisor to give advice about the situation

Ask a supervisor to give advice about the situation

A nurse is collecting data from a client who has conduct disorder. Which of the following findings should the nurse expect? A. Fearfulness of authority figures B. Flat affect C. Preoccupation with enforcing rules D. Aggressive behavior toward others

Aggressive behavior toward others *The nurse should expect a client who has conduct disorder to exhibit aggression towards others and impulsively violate others' rights

A nurse is caring for a client with schizophrenia who started taking a first-generation antipsychotic medication 3 weeks ago. The client reports a feeling of inner restlessness, rocks back and forth when sitting down, and paces frequently. The nurse should identify that the client is experiencing which of the following adverse effects of antipsychotic medications? A. Neuroleptic malignant syndrome B. Akathisia C. Anticholinergic toxicity D. Opisthotonos

Akathisia *Akathisia is an extrapyramidal adverse effect that occur in a client within the first 2 months after beginning a first-generation antipsychotic medication. The client might be unable to rest due to a feeling of inner restlessness. Rocking back and forth and pacing the floor can also be manifestations of akathisia. The nurse should report this finding to the provider. Several medications such as propranolol can be used to treat akathisia

A patient with psychotic depression is receiving haloperidol. Which side effect is associated with this medication? A. Cataracts B. Akathisia C. Polyuria D. Diaphoresis

Akathisia *Akathisia is pathologic restlessness and agitation; it is an extrapyramidal adverse effect of many of the older antipsychotic medications, such as haloperidol and chlorpromazine. Polyuria, cataracts, and diaphoresis are not associated with haloperidol use.

A nurse is collecting data for a client who has anorexia nervosa. Which of the following findings should the nurse expect? A. Hyperthermia B. Alopecia C. Hypertension D. Warm skin

Alopecia *The nurse should expect a client who has anorexia nervosa to have alopecia, which is a finding consistent with malnourishment and dehydration. The client may also have lanugo (fine, downy hair growth) on the face and back

Which medication is mainly used to treat anxiety? A. Paroxetine (Paxil) B. Alprazolam (Xanax) C. Phenelzine (Nardil) D. Amitriptyline (Elavil)

Alprazolam (Xanax)

The spouse of a patient with alcohol use disorder makes excuses to their children when the patient fails to do things that were promised. What is the priority problem? A. Limited coping ability B. Altered family functioning C. Absence of compliance D. Decreased self-esteem

Altered family functioning *The spouse is trying to maintain the family because the patient is unable to do so because of alcohol abuse. (1) It is likely that none of the family members are coping well; however, the scenario mostly discloses family dysfunction. (3) Nothing in the question mentioned absence of compliance with a treatment plan. (4) The parents may have a decreased sense of self-esteem in this situation, but nothing in the question mentions this.

A nurse in an acute mental health facility is reviewing the medication records of a group of clients. The nurse should expect a prescription for memantine for a client who has which of the following diagnoses? A. Depression B. Schizophrenia C. Obesity D. Alzheimer's disease

Alzheimer's disease *The nurse should expect a prescription for memantine for a client who has moderate to severe Alzheimer's disease. Memantine, an NMDA receptor agonist, is shown to slow the progression of manifestations and to improve cognitive function

A nurse delegates a newly licensed nurse to provide one-on-one observation for a client who requires suicide precautions. Which of the following actions by the newly licensed nurse indicates the need for further reinforcement of teaching? A. Accompanies the client to physical and occupational therapy B. Ambulates the client's roommate while the client sleeps C. Asks the nurse at lunch time to assign another newly licensed nurse to perform this task D. Remains with the client while family members are visiting

Ambulates the client's roommate while the client sleeps *One-on-one observation requires constant supervision of the client. The client might wake up and engage in self-injuries behavior while the newly licensed nurse is caring for the other client

A nurse is assisting with the collection of admission data for a client who has anorexia nervosa. The client has lost 11.4 kg (25 lb) over the past month and currently weights 38.6 kg (85 lb). The nurse should expect which of the following findings? A. Flushed extremities B. Hyperkalemia C. Loose stools D. Amenorrhea

Amenorrhea *The nurse should expect this client who has anorexia nervosa to have amenorrhea due to low body weight

A nurse in an acute mental health facility is participating in a nursing staff discussion about the legal aspects of involuntary admissions. Which of the following pieces of information should the nurse include? A. A client who is involuntarily admitted must take prescribed medications B. An involuntary admission of a client is limited to 2 weeks C. A client who is involuntarily admitted can leave the facility against medical advice D. An involuntary admission is justified if the client is a danger to others

An involuntary admission is justified if the client is a danger to others *A client who is a danger to others or to self qualifies for an involuntary admission. The inability to meet basic needs due to the need for mental health treatment is also a justification for an involuntary admission

A nurse is assisting with the admission of a client who has antisocial personality disorder to an acute care unit. The client is admitted under court order following the theft and destruction of a car. Which of the following behaviors should the nurse expect the client to display? A. Relief about finally receiving care for a problem for which was previously afraid to ask for B. Anger with the nursing staff for hospitalizing him against his will C. Withdrawal from others due to shame over his recent actions D. Remorse for stealing and destroying the car

Anger with the nursing staff for hospitalizing him against his will *A client who has antisocial personality disorder exhibits a low frustration level and can quickly become angry and aggressive when the situation goes against his will or desires

A nurse in a provider's office is documenting the results of a general survey of a client who is new to the practice. The client reports an inability to find pleasure in any activities she previously enjoyed. Which of the following terms should the nurse use to describe the client's mood? A. Anergia B. Flat effect C. Apathy D. Anhedonia

Anhedonia *Anhedonia is an inability to experience pleasure. This finding is especially concerning when the client no longer enjoys the activities that once produced pleasure

A nurse on an eating disorders acute care unit is collecting data from a client and observes the presence of lanugo on her skin. The nurse should identify that this finding is consistent with which of the following eating disorders? A. Anorexia nervosa B. Bulimia nervosa C. Binge eating disorder D. Pica

Anorexia nervosa *Anorexia nervosa is an eating disorder associated with severe food restriction. Clients who have anorexia nervosa are often underweight and might have lanugo (fine, downy hair) on the back and face

During report, the nurse is told that a patient has Cluster B group type of personality disorder. Which type of behavior can the nurse anticipate? A. Paranoia B. Avoidance C. Antisocial behavior D. Obsessive-compulsive disorder

Antisocial behavior *The antisocial personality disorder is included in Cluster B: dramatic and erratic

A nurse in an acute substance disorder unit is collecting data from a client who received treatment in the emergency department for an opioid overdose. Which of the following findings should the nurse anticipate during opioid withdrawal? A. Calmness B. Anxiety C. Hypotension D. Bradycardia

Anxiety *The nurse should expect the client to have anxiety during opioid withdrawal

The nurse explains that anxiety disorders differ from normal anxiety. Which statement accurately describes anxiety disorders? A. Anxiety disorders develop into suicidal tendencies B. Anxiety disorders are seldom controlled C. Anxiety disorders interfere with effective functioning D. Anxiety disorders make maintenance of relationships impossible

Anxiety disorders interfere with effective functioning *Anxiety disorders interrupt normal day-to-day functioning in the workplace and in family settings

A nurse is caring for a client who has schizophrenia. The nurse notices that the client is pacing up and down the hall rapidly and muttering in an angry manner. Which of the following actions should the nurse take first? A. Apply mechanical restraints to the client B. Administer PRN haloperidol IM to the client C. Approach the client in a nonthreatening manner D. Place the client in seclusion

Approach the client in a nonthreatening manner *The first action the nurse should take is to approach the client calmly to create a nonthreatening environment.

The nurse is changing the dressing on self-inflicted cigarette burns on a patient with borderline personality disorder. When providing the care, which action is most therapeutic? A. Change the dressing while being nurturing and caring to keep patient from feeling abandoned B. Approach the dressing change with matter-of-fact demeanor to decrease secondary gains of sympathy C. Present a stern attitude to underscore the seriousness of the act D. Interact in a professional and distant manner to diminsh the opportunity for manipulation

Approach the dressing change with matter-of-fact demeanor to decrease secondary gains of sympathy *The person with the borderline personality disorder will seek additional secondary gains in terms of attention about the manipulative act of self-mutilation. Nurturing with reinforce the effectiveness of the mutilation to gain attention. Stern and distant demeanors may appear confrontational to the patient and reduce the therapeutic aspects of the intervention

What information will best help the nurse determine whether the patient is experiencing a threat to his mental health? A. Opinion of the health care provider B. Opinion of family members C. Appropriateness of behavior to a situation D. Intelligence testing and educational level

Appropriateness of behavior to a situation *Appropriate behavior is an indicator of mental health. Although significant, the family's opinion, health care provider's opinion, and intelligence level may not consistently correlate with mental health status.

A nurse is caring for a client who has cirrhosis of the liver due to alcohol use disorder. Which oft he following findings should the nurse expect? A. Acrocyanosis B. Arrhythmias C. Ascites D. Weight gain

Ascites *The nurse should expect this client who has cirrhosis of the liver to exhibit gastrointestinal and hepatic manifestations due to the destruction of liver cells. Ascites results from the accumulation of serous fluid in the abdominal cavity due to portal hypertension. Jaundice, weight loss, and esophageal varices are other expected findings of this disorder

A nurse is caring for a client who is experiencing delusions. Which of the following actions should the nurse take? A. Focus on the client's delusions B. Debate the content of the delusions with the client C. Validate that the delusions are real D. Ask the client to describe his feelings about the delusions

Ask the client to describe his feelings about the delusions *The nurse should ask the client to describe his feelings and beliefs about delusions. Identifying these feelings and beliefs can help determine the underlying issues and feelings that the client needs to address

A nurse is performing a neurological examination for a client. To collect data about a client's level of attention, the nurse should do which of the following? A. Point to 2 objects and ask the client to name them B. Ask the client to name the months of the year in reverse C. Say 3 words and ask the client to repeat them D. Ask the client to write a sentence

Ask the client to name the months of the year in reverse *The nurse should evaluate the client's ability to concentrate by asking the client to name the months of the year in reverse order

A nurse is assisting with the admission of a client who reports hearing voices telling him what to do. Which of the following actions should the nurse take? A. Instruct the client to sit in a quiet place when he hears voices B. Ask the client to repeat what the voices are saying C. Tell the client that the voices do not exist D. Provide therapeutic touch when the client seems anxious

Ask the client to repeat what the voices are saying *The nurse should ask the client directly what the voices are saying to determine if the client or others are in danger or at risk for injury

A nurse is caring for an adult client who has alcohol use disorder. The client states she is refusing further treatment and is leaving the mental health facility. Which of the following actions should the nurse take? A. Request a prescription for restraints from the provider B. Notify security and ask them to lock the unit's exit doors C. Notify the client's family of her intent to leave D. Ask the client to sign an against medical advice form

Ask the client to sign an against medical advice form *The client has the right to refuse treatment and leave the mental health facility unless involuntarily committed. The nurse should ask the client to sign an against medical advice (AMA) form stating that she is choosing to leave the facility against the recommendation of her provider

A nurse is caring for a client who has schizophrenia and is becoming anxious due to auditory hallucinations. Which of the following actions should the nurse take? A. Offer the client therapeutic touch B. Ask the client what he is hearing C. Affirm the presence of the voices D. Move the client into a more stimulating environment

Ask the client what he is hearing *The nurse should ask the client about what he is hearing to determine if the hallucination is causing fear or distress to the client. Also, the nurse needs to determine if the hallucination may cause the client to harm himself or others. However, asking the client, "What are the voices saying to you?" can infer that the nurse believes the voices are real

A nurse is caring for a client who has schizophrenia and is hearing voices. Which of the following actions is the nurse's priority? A. Ask the client what the voices are saying B. Focus the client's attention on reality-based activities C. Make eye contact when speaking with the client D. Encourage the client to listen to music through headphones

Ask the client what the voices are saying *The greatest risk for this client is an injury to self or others due to command hallucinations. Command hallucinations can be a psychiatric emergency. Therefore, the nurse's priority is to ask the client what the voices are saying

A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take? A. Stop the interview at this point, and resume later when the client is better able to concentrate. B. Ask the client, "Are you seeing something on the ceiling?" C. Tell the client, "You seem to be looking at something on the ceiling. I see something there, too." D. Continue the interview without comment on the client's behavior.

Ask the client, "Are you seeing something on the ceiling?" *Ask the client directly about the halluncation to identify client needs to monitor for a potential risk for injury *Address the client's current needs related to the possible hallucincation rather than stop the interview *Avoid agreeing with the client, which can promote psychotic thinking *Address the client's current needs related to the possible hallucination rather than ignoring the change in behavior

A nurse is observing a client who has schizophrenia. The client is in the dayroom when another client asks him if 2 items of clothing match. He replies, "A match. I like matches. They are the givers of light, the light of the world. God will light the world. Let your light shine on." The nurse should identify these statements as which of the following speech alterations? A. Clang association B. Echolalia C. Word salad D. Associative looseness

Associative looseness *This client is demonstrating associative looseness, a pattern of disordered speech that reflects haphazard and illogical thoughts in succession

A nurse wants to use democratic keadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when demonstrating which of the following actions? A. Observes group techniques without interfering interfering with the group process B. Discusses a technique and then directs members to practice of the technique C. Asks for group suggestions of techniques and then supports discussion D. Suggests techniques and asks group members to reflect on their use

Asks for group suggestions of techniques and then supports discussion *Democratic leadership supports group interaction and decision making to solve problems *Laissez-faire leadership allows the group process to progress without any attempt by the leader to control the direction of the group *Autocratic leadership controls the direction of the group

A nurse on an inpatient mental health unit is attending an interdisciplinary treatment team meeting for a client who has bipolar disorder with rapid cycling. The client is being prepared for discharge following his fourth admission in the last year. Which of the following referrals should the nurse make for the client first? A. Assertive community treatment B. Supportive group C. Private counseling D. Vocational rehabilitation services

Assertive community treatment *Evidence-based practice indicates the nurse should first refer the client to an assertive community treatment (ACT). An ACT program should be most beneficial for this client who has bipolar disorder with rapid cycling, as professional help will be available to the client 24 hours a day for crisis management. A multidisciplinary team approach assists clients in managing their mental illness so inpatient hospitalization can be avoided

The nurse is aware the patient with brderline personality disorder did not have a family visit this week and adds an intervention to address the patient's perception of abandonment. Which intervention is most appropriate? A. Schedule the patient for pet therapy visit B. Arrange for remote activity during next visiting time C. Assess daily for evidence of self-mutilation D. Assign a young CNA to his care

Assess daily for evidence of self-mutilation *Patients with borderline personality disorder have a deep fear of abandonment and react with intense, emotionally charged acts, such as suicide attempts of self-mutilation

What is the priority action when you are caring for a patient with active hallucination? A. Assess the content and themes of hallucinations B. Give an antipyschotic medication C. Take the patient to a secluded area D. Set boundaries and explain rationale

Assess the content and themes of hallucinations *Assess the content and theme of hallucinations to determine if there is a danger to self or others. (2, 3) Based on your assessment, you may decide that medication or isolation is necessary. (4) Setting boundaries does not alleviate the hallucinations; however, you should explain your actions if you medicate or isolate.

The nurse adds an intervention to the nursing care plan for a patient on neuroleptics. Which intervention is most appropriate? A. Increase fluid intake to compensate for the side effect of diarrhea B. Encourage snacks to prevent weight loss C. Monitor vital signs for hypertension D. Assess urinary output for evidence of urinary retention

Assess urinary output for evidence of urinary retention *Neuroleptics cause urinary retention, weight gain, constipation, and hypotension. Diarrhea is not assiciated with the administration of neuroleptics. Weight gain, and not weight loss, is associated with this type of medication. Hypertension is not associated with this type of medication

The patient with delirium is combative and is putting herself and others at risk. Which nursing intervention should be implemented as an alternative to restraint use? A. Turn the TV up loud to distract the patient. B. Use all four side rails to prevent the patient from getting out of bed. C. Assign a sitter for one-on-one observation. D. Place the patient in a room away from the nurse's station.

Assign a sitter for one-on-one observation. *Nursing interventions that can be used as an alternative to restraints include assigning a sitter for one-on-one observation, reducing noise, and keeping the patient close to the nurse's station. Use of all four side rails should be avoided as it is a strangling hazard and is considered a type of restraint. Three side rails may be used to prevent the patient from rolling out of bed.

The nurse is planning care for patients with cognitive disorders. Which task can be assigned to the nursing assistant? A. Determine which patients need assistance with hygienic care B. Evaluate the patient' responses to reality-orientation therapy C. Assist patients to ambulate in the hall or enclosed courtyard D. Observe patients for changes in mental status during the shift

Assist patients to ambulate in the hall or enclosed courtyard

A nurse is assisting a client whose house was just destroyed by a fire. Which of the following actions should the nurse take? A. Assist the client in identifying resources B. Give the client a time frame in which to find shelter C. Assure the client that everything will work out D. Encourage the client to focus on actions and not emotions

Assist the client in identifying resources *The client who is experiencing a crisis will often feel overwhelmed by the event. The nurse should assist by offering emotional support and identifying resources to help the client

A nurse is collecting data from a client who has schizophrenia and was recently admitted to acute care. Which of the following findings should the nurse expect? A. Seductive behaviors B. Obsession with rituals C. Uncontrolled appetite D. Associative looseness

Associative looseness *The nurse should recognize associate looseness (speech that reveals though patterns that shift rapidly between topics) as a common finding in a client who has schizophrenia. Other findings include the presence of delusions, hallucinations, and altered speech patterns such as echolalia

A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons? A. Nacissistic behavior B. Fear of rejection from staff C. Attempt to reduce anxiety D. Adverse effect of antidepressant medication

Attempt to reduce anxiety *Clients who have OCD demonstrate repetitive behavior in an attempt to suppress persistent thoughts or urges that cause anxiety *Narcissism causes clients to seek admiration from others *Fear of rejection might cause a client to avoid social situations and might be associated with social phobia anxiety disorder *Clients who have OCD might take an antidepressant to help control repetitive behavior

A nurse is caring for a client who spent the past several minutes mumbling about being "doomed to die." The client is now pacing in an increasingly agitated and angry manner. Which of the following actions is the nurse's priority? A. Obtain a prescription for PRN medication for agitation B. Attempt to reduce environmental stimuli C. Request a prescription for physical restraints D. Place the client in seclusion

Attempt to reduce environmental stimuli *Least restrictive to the client that does not jeopardize the client's safety

A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe metal illness and requires supervision. The client's partner works all day but is home by late afternoon. Which of the following strategies should the nurse suggest for follow-up care? A. Receiving daily care from a home health aide B. Having a weekly visit from a nurse case worker C. Attending a partial hospitalization program D. Visting a community mental health center on a daily basis

Attending a partial hospitalization program *A partial hospitalization program can provide treatment during the day while allowing the client to spend nights at home, as long as a responsible family member is present *Daily care provided by a home health aide and weekly visits from a case worker will not provide adequate supervision for this client *Daily visits to a community mental health center will not provide consistent supervision for this client

A nurse is caring for a cliet who has a new prescription for disulfiram for treatment of alcohol use disorder. The nurse informs the client this medication can cause nausea and vomiting when alcohol is consumed. Which of the following types of treatment is this method an example? A. Aversion therapy B. Flooding C. Biofeedback D. Dialectical behavior therapy

Aversion therapy *Aversion therapy pairs a maladaptive behavior with unpleasant stimuli to promote a change in behavior. *Flooding is planned exposure to an undesirable stimulus in an attempt to turn off the anxiety response *Biofeedback is a behavioral therapy to control pain, tension, and anxiety *Dialectical behavior therapy is a cognitive-behavioral therapy for clients who have a personality disorder and exhibit self-injurious behavior

A nurse is reinforcing teaching to a client who has tobacco use disorder about the use of nicotine gum. Which of the following information should the nurse reinforce? A. Chew the gum for no more than 10 min B. Rinse out the mouth immediately before chewing the gum C. Avoid eating 15 min prior to chewing the gum D. Use of the gum is limited to 90 days

Avoid eating 15 min prior to chewing the gum *The client should avoid eating or drinking 15 min prior to and while chewing the gum *The client should chew the gum slowly and intermittently over 30 min *The client should avoid drinking 15 min prior to chewing gum *Use of nicotine gum is not recommended for longer than 6 months

A nurse in a provider's office is reviewing the laboratory reports of a client who has bulimia nervosa. Which of the following laboratory values indicates a therapeutic response to the treatment plan? A. BUN 15 mg/dL B. Potassium 3.2 mEq/L C. Sodium 130 mEq/L D. Hematocrit 54%

BUN 15 mg/dL *Clients who have bulimia nervosa often have increased BUN levels due to dehydration. This level is within the expected reference range of 10 to 20 mg/dL, indicating a therapeutic response to the treatment plan

A nurse is caring for a client who is terminally ill. The client states, "if only I had gone to my doctor earlier." The nurse should identify that the client is in which of the following Kubler-Ross stages of grief? A. Bargaining B. Anger C. Depression D. Denial

Bargaining *The client is in the bargaining stage of grief. During this stage, the client can have feelings of helplessness and vulnerability

Which classic behavior characterizes bulimia? A. Bingeing and purging B. Refusal to eat C. Excessive exercising D. Hiding food to make it appear it was eaten

Bingeing and purging *Patients with bulimia nervosa induce vomiting after consuming large quantities of food. This binge eating occurs in a frenzied state and usually in secrecy; afterward, the patient experiences feelings of shame and self-criticism. Laxatives may be taken to purge the system after the binge. 90% of patients with bulimia are young women

A nurse is attending a peer group discussion about the indications for ECT. Which of the following indications should the nurse recommend for inclusion in the discussion? A. Borderline personality disorder B. Acute withdrawal related to a substance use disorder C. Bipolar disorder with rapid cycling D. Dysphoric disorder

Bipolar disorder with rapid cycling *ECT is indicated for the treatment of bipolar with rapid cycling *ECT has not been found to be effective for the treatment of personality disorders, substance use disorders, or dysphoric disorder

The nurse is caring for a patient who was admitted for a lorazepam (Ativan) overdose. Which assessment finding indicates that the patient is experiencing withdrawal? A. Lethargy B. Urine output of 40 mL/h C. Heart rate of 48 beats per minute D. Blood pressure of 140/90

Blood pressure of 140/90 *Elevated blood pressure is consitent with withdrawal from a central nervous system (CNS) depressant like lorazepam (Ativan), a benzodiazepine. If an individual has been abusing drugs that depress the CNS and goes through withdrawal, other symptoms would include an elevation in pulse, nervousness, and heightened anxiety. The patient would likely be agitated rather than lethargic and tachycardic. Urine outpur of 40 mL/h is a normal finding

A nurse is reinforcing teaching with a client who has a new prescription for lorazepam to treat alcohol withdrawal. Which of the following should the nurse identify as an adverse effect of lorazepam that the client should report to the provider? A. Increased thirst B. Sweating C. Blurred vision D. Facial flushing

Blurred vision *The nurse should inform the client that blurred vision is an adverse effect of lorazepam and instruct the client to notify the provider if this occurs

A nurse is collecting data from a client who is taking lithium to treat bipolar disorder and has a lithium level of 2.2 mEq/L. Which of the following findings should the nurse expect? A. Muscle weakness B. Oliguria C. Vomiting D. Blurry vision

Blurry vision *Manifestations of lithium toxicity with levels between 2 and 2.5 mEq/L include blurry vision, ataxia, clonic twitching, severe hypotension, and polyuria

The nurse is aware that when Korsakoff syndrome is suspected from behavioral cues, the syndrome can be confirmed by which diagnostic test? A. Liver biopsy B. Brain scan C. Magnetic resonance imaging D. Spinal tap

Brain scan *The individual with Korsakoff syndrome has grossly impaired memory and gait disturbance. Confabulation (making up stories) frequently is seen as an attempt to communicate. A brain scan will show brain atrophy; currently, there is no treatment to reverse the condition

A nurse is reinforcing teaching with a client who has generalized anxiety disorder to perform a deep-breathing exercise. Which of the following actions should the nurse instruct the client to take? A. Utilize chest breathing B. Breathe in through the nose C. Keep the shoulder erect D. Repeat the exercise for at least 10 minutes for effectiveness

Breathe in through the nose *When using deep-breathing exercises, clients should breathe in through their noses, hold their breath for about 3 seconds, and then exhale through their mouths

A nurse on a mental health unit is caring for a client who has depression. Which of the following actions should the nurse take to foster a therapeutic environment for this client? A. Tell the client that the nurse will talk to him at his request B. Allow the client to skip group activities if he chooses C. Leave the client alone for frequent rest periods throughout the day D. Build trust with the client by sitting quietly with him

Build trust with the client by sitting quietly with him *The nurse should build trust with the client to convey interest in the client's concerns. Offering self by sitting with the client and using silence are actions that promote trust, which encourages the client to speak more openly about issues and concerns

Why do many people who abuse Cannabis (marijuana) rationalize their use? A. Cannabis sedates them B. Cannabis explands their senses C. Cannabis heightens sexual pleasure D. Cannabis is legal everywhere so it is ok

Cannabis explands their senses *Many young people offer the increased sensitivity to sound, colors, and other environmental elements as a rationale for using the nonaddicting drug

A nurse is reviewing the medical history of a client who has a new prescription for electroconvulsive therapy (ECT). Which of the following findings should the nurse identify as the priority? A. Severe depression B. Cardiac arrhythmia C. Bipolar disorder D. Parkinson's disease

Cardiac arrhythmia *A client who has cardiac arrhythmias need further evaluation. The nurse should identify that the greatest risk for death due to ECT is related to cardiac complications

A nurse is caring for a client who has anorexia nervosa. The client states, "If I gain weight, I'll never get a boyfriend." Which of the following cognitive distortions is the client displaying? A. Overgeneralization B. Personalization C. Emotional reasoning D. Catastrophizing

Catastrophizing *A client displays the cognitive distortion of catastrophizing by assuming the worst possible outcomes will occur

A nurse in an ambulatory clinic is caring for a client who has an injured arm and periorbital ecchymosis. The nurse suspects intimate partner violence. Which of the following nursing interventions should the nurse take first? A. Notify the nursing supervisor B. Prepare the client for an X-ray C. Contact social services D. Check the client's injuries

Check the client's injuries *The first action the nurse should take using the nursing process is to assess the client

A nurse is caring for a client who has conduct disorder and is displaying violent behavior. After several attempts to provide a diversion, the nurse applies a physical restraint. Which of the following actions should the nurse take? A. Check the client's physical needs every 30 minutes B. Obtain the client's vital signs once per shift C. Tie the restraint to the side rail of the client's bed D. Use square knots to secure the client's restraint

Check the client's physical needs every 30 minutes *While the client is in restraints, the nurse should check the client's physical needs every 30 minutes. The nurse should offer food and hydration and should allow the client to use the bathroom if necessary. The nurse should also document these findings

A patient is experiencing anticholinergic side effects from the drug to counter side effects of his antipsychotic medication. The nurse should suggest which interventions to relieve dry mouth? A. Chew gum, perform mouth hygiene, and increase fluids B. Encourage fluids, increase fiber in diet, and suck on hard candy C. Decrease the medication dosage and perform mouth hygiene every 2 hours D. Track fluid intake, drink milkshakes, and chew gum

Chew gum, perform mouth hygiene, and increase fluids

A nurse is caring for a client who has schizophrenia. The client states, "I like to play ball. Walk down the hall. Be careful; don't fall." The nurse should identify that the client is using which of the following patterns? A. Pressure speech B. Circumstantial speech C. Clang association D. Flight of ideas

Clang association *The nurse should recognize that this client is displaying clang association. Clang association is the stringing together of words because of their rhyming sounds, regardless of their meaning.

A nurse is collecting data from a client who has schizophrenia. The client suddenly states, "I'm blue, so are you, and I'm leaving on a choo, choo, choo!" The nurse should identify the client's statement as which of the following speech patterns? A. Clang association B. Word salad C. Neologism D. Echolalia

Clang association *This statement demonstrates clang association, a pattern of speech often used by clients who have schizophrenia. This pattern of speech often includes rhyme or a string of words that have the same beginning sounds

How should the nurse speak when communicating with a patient with moderate Alzheimer dementia? A. Slowly B. Clearly C. Loudly D. Softly

Clearly *Clarity is essential when communicating with a patient with Alzheimer dementia. placing self directly in front of the patient and using pictures or symbols is helpful

Processes of perception, memorym and judgment A. Cognition B. Dementia C. Delirium

Cognition

You recognize which of the following as symptoms associated with delirium? A. Fading short-term memory, withdrawn behavior, and depression B. Inattention to hygiene, sad countenance, little verbal expression C. Confusion, incoherent speech, sudden onset of symptoms D. Inability to recognize familiar objects, angry outbursts, confusion

Confusion, incoherent speech, sudden onset of symptoms *Patients with delirium have symptoms of confusion and incoherent speech, with the sudden onset of symptoms. (1) Fading short-term memory, withdrawn behavior, and depression are characteristic of Alzheimer disease. (2) Inattention to hygiene, sad countenance, and little verbal expression are common in moderate Alzheimer disease. (4) Inability to recognize familiar objects, angry outbursts, and confusion are particular to moderate to severe Alzheimer disease.

A young man with suspected heroin intoxication is admitted to the unit. Which sign is consistent with opiate use? A. Elevated blood pressure (BP) B. Rapid speech C. Dilated pupils D. Constricted pupils

Constricted pupils *Opiate use causes constricted pupils; opiate overdose results in dilated pupils as a result of cerebral anoxia. However, there is no information given to indicate overdose. Opiate use results in slowed speech and decreased BP.

The home health nurse is counseling a family who will be caring for a relative with moderate-stage Alzheimer disease (AD). Which information is most important to include? A. Construct a consistent routine to provide structured environment B. Try to make each day different to enhace attention span C. Use multiple caregivers to decrease unhealthy attachment and prevent caregiver burnout D. Place bright rugs, flower arrangements, and wall decorations around the room to stimulate sensory perception

Construct a consistent routine to provide structured environment *A consistent routine--eating, resting, medication, hygient--are all beneficial to the demented patient. Different caregivers and distracting environmental objects increase confusion

The nurse is caring for an undernourished alcoholic patient. The nurse is helping the patient to select items from the menu. What dietary goal should the nurse try to help the patient achieve? A. Construct a diet that consists of at least 30% protein B. Limit all fat and cholesterol C. Limit sodium intake to less than 1.5 g D. Construct a diet that consists of at least 50% carbohydrates

Construct a diet that consists of at least 50% carbohydrates *The diet for the malnourished alcoholic should be high in protein and consist of at least 50% carbohydrates. There are no specific limitations for fat, cholesterol, or sodium

You are caring for an 18-year-old patient who is diagnosed with anorexia nervosa. What is an appropriate expected outcome for the patient? A. Consume 35% or more of meals B. Develop improved eating behaviors C. Verbalize the importance of eating D. Identify barriers to eating

Consume 35% or more of meals *"Able to eat 35% or more of meals" is a concrete and realistic goal. (2) "Able to develop improved eating behaviors" is too vague and broad. (3) Focusing on the importance of food or the patient's resistance to eating will only lead to power struggles. (4) The primary barrier to eating is the patient.

A nurse is assisting with the care of a client who has schizophrenia and is being discharge from an acute mental health setting. Which of the following should be included in the discharge plan? A. Refer the client to respite care services B. Provide a list of primary preventative mental health group C. Enroll the client in a 12-step program D. Contact an intensive outpatient program

Contact an intensive outpatient program *A client who has received in-patient treatment for schizophrenia can benefit from an intensive outpatient program. These programs allow clients to receive step-down care similar to what was provided in the inpatient setting to stabilize their condition further

A nurse is reviewing the medical record of a client who has conversion disorder. Which of the following findings should the nurse identify as placing the client at risk for conversion disorder? A. Death of a child 2 months ago B. Recent weight loss of 30 lb C. Retirement 1 year ago D. History of migraine headache

Death of a child 2 months ago *The death of a child 2 months ago is an acute stressor that places the client at risk for conversion disorder *A recent weight loss of 30 lb does not place the client at risk for conversion disorder. Recent acute stress can be a risk factor *Retiring 1 year ago does not place the client at risk for conversion disorder. PTSD can be a risk factor *A history of migraine headaches does not place the client at risk for conversion disorder. History of depression can be a risk factor

What factors cause elderly patient to be at risk for substance-induced delirium? A. Increased metabolism and reduction in cardiac and liver function B. Decreased metabolism and reduction in cardiac and respiratory function C. Decreased metabolism and reduction in kidney and liver function D. Increased metabolism and reduction in neurologic and immune function

Decreased metabolism and reduction in kidney and liver function

An acute alteration in cognition A. Cognition B. Dementia C. Delirium

Delirium

Experiences an illusion A. Cognition B. Dementia C. Delirium

Delirium

Results from cerebrovascular accident A. Cognition B. Dementia C. Delirium

Delirium

The LPN/LVN reads on a patient's chart that the patient had a sudden onset of confusion with incoherent speech. The patient is likely to be diagnosed with what cognitive disorder? A. Depression B. Delirium C. Alzheimer disease D. Dementia

Delirium *Delirium (acute confusion) is characterized by a change in overall cognition and level of consciousness over a short time. Dementia is characterized by several cognitive deficits, memory in particular, and tends to be more chronic. The difference between the two conditions is that delirium is an acute condition that requires immediate treatment, and is reversible, whereas dementia is a chronic condition that is irreversible. Alzheimer disease is a type of dementia. Depression is not associated with sudden confusion and incoherent speech.

An 85-year-old man is admitted to the hospital with gastroenteritis and dehydration. He receives a dose of meclizine hydrochloride, an anticholinergic, for vomiting. He begins to hallucinate and talk to his wife, who has been dead for 10 years. Which explanation best describes this behavior? A. Dementia related to advanced age B. Delirium related to dehyrdration C. Demential related to early Alzheimer's disease (AD) D. Delirium related to side effect of anticholinergic

Delirium related to side effect of anticholinergic *Anticholinergic drugs can cause sudden confusion in older adults. There is nothing in the history that suggests that the behavior would be related to AD or any other dementia as dementias progress slowly. Dehydration would increase the effect of the anticholinergic

Characterized by slow onset A. Cognition B. Dementia C. Delirium

Dementia

Uses confabulation to cover memory gaps A. Cognition B. Dementia C. Delirium

Dementia

A public health nurse is planning methods of providing health assistance for community members. Which of the following community interventions is an example of primary prevention? A. Serving as a staff member in a rape crisis center B. Provide referrals to 12 step programs for community members being discharged from rehabilitation centers C. Demonstrating stress-release exercises to members of the community D. Leading a support group for newly divorced community members

Demonstrating stress-release exercises to members of the community *This intervention is an example of primary prevention. By instructing community members about ways to manage stress, the nurse can assist in minimizing the harmful effects of stress that can lead to future illness

A nurse is caring for a client who has alcohol use disorder and claims that her family is "exaggerating the problem." The nurse should identify this behavior as which of the following defense mechanisms? A. Denial B. Introjection C. Regression D. Rationalization

Denial *Denial involves actions and statements by the client that do not acknowledge the reality of the situation

The alcoholic patient says to the nurse: "I am not an alcoholic. I can quit any time I want to." The nurse recognizes that the patient is using which defense mechanism? A. Repression B. Denial C. Rationalization D. Intellectualization

Denial *Denial is ignoring reality in spite of hard evidence. Denial is a mechanism frequently used by substance abusers/ Repression refers to unconsciously blocking an unwanted thought or memory from open expression. Rationalization attempts to justify a behavior or action by making an excuse or an explanation. Intellectualization is the excessive reasoning and logic to counter emotional distress

A nurse is caring for a client who has newly diagnosed with breast cancer that has metastasized in to the spine. The client refuses to discuss treatment options. The nurse should identify that the client is experiencing which of the following stages of Kubler-Ross' grief theory? A. Anger B. Bargaining C. Denial D. Depression

Denial *During the first stage, denial and refusal to accept the imminence of the loss are self-protection mechanisms that allow the client to process the diagnosis. During this stage, the client has difficulty accepting the loss or diagnosis and might refuse to discuss the impending or actual loss during this stage. The client might also be convinced that a mistake has been made and that there is no loss

A nurse is caring for a client who just received a terminal diagnosis of cancer. Which of the following initial reactions should the nurse expect from the client? A. Bargaining B. Depression C. Denial D. Anger

Denial *The nurse should expect the client to deny the reality of the diagnosis initially. This is a protective reaction seeking to avoid psychological pain

A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client using which of the following defense mechanisms? A. Reaction formation B. Denial C. Displacement D. Sublimation

Denial *This is an example of denial, which is pretending the truth is the not the reality to manage the anxiety of acknowleding what is real *(A) This is not an example of reactio formation, which is overcompensating or demonstrating the opposite behavior of what is felt *(C) This is not an example of displacement, which is shifting feelings related to an object, person, or situation to another less threatening object, person, or situation *(D) This is not an example of sublimation, which is dealing with unacceptable forms of expression

What are the two main defense mechanisms used by substance users? A. Repression and regression B. Sublimation and splitting C. Denial and rationalization D. Displacement and identification

Denial and rationalization

A nurse is reviewing the medical record of a client who has bulimia nervosa. Which of the following findings should the nurse expect? A. Elevated creatinine level B. Decreased white blood cells C. Dental erosion D. Cachexia

Dental erosion *The nurse should expect dental erosion in a client who has bulimia nervosa. The binging and purging behavior with induced vomiting leads to dental caries and enamel erosion from the hydrochloric acid content of emesis. Induced vomiting can also cause parotid swelling. Continued vomiting can place the client at risk of esophageal or gastric rupture

The nurse is educating a patient who has just been prescribed diazepam (Valium). The nurse cautions the patient that diazepam (Valium) may cause which problem? A. Dependency B. Urinary retention C. Severe dehydration D. Hallucinations

Dependency *Valium can cause a physiologic and a psychological dependence. Valium should not cause urinary retention, severe dehydration, or hallucinations

A nurse is caring for a client who has a stimulant use disorder. Which of the following manifestations should indicate to the nurse that the child is experiencing withdrawal? A. Mental alertness B. Tachycardia C. Depression D. Dilated pupils

Depression *A client who has a stimulant use disorder and is experiencing withdrawal can experience depression. Other manifestations of stimulant withdrawal can include fatigue, paranoia, craving for stimulants, anxiety, increased appetite, poor concentration, hypersomnia or insomnia, and irritability

A nurse in the emergency department is assisting with the care of a client who sustained minor injuries in a motor vehicle crash. The client's spouse was killed in the accident. Which of the following actions should the nurse take first? A. Determine if the client has thoughts of self-harm B. Ask the client how the accident occurred C. Assist the client in setting short-term treatment goals D. Instruct the client on use of coping strategies

Determine if the client has thoughts of self-harm *The greatest risk to the client experiencing a crisis is the risk of harm to himself or others. Therefore, determining if the client has thoughts of self-harm is the action to take first.

A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of the following actions is the nurse's priority? A. Offer the client finger foods every 2 hr B. Determine if the client is a danger to herself C. Monitor the client's vital signs every 2 hr D. Move the client to a quiet area

Determine if the client is a danger to herself *The greatest risk to this client is an injury from hyperactivity or life-threatening exhaustion. Therefore, the priority action is to determine whether the client has feelings of suicide or is showing manifestations of exhaustion

A nurse in a community urgent care facility is helping plan interventions for clients who experience sexual assault. Which of the following actions should be included in the teaching? A. Determine if the client is experiencing thoughts of self-harm B. Postpone collection of forensic evidence if a sexual assault nurse examiner is not available C. Encourage the client to shower before undergoing a physical examination D. Assess the client for the presence of a maturational crisis

Determine if the client is experiencing thoughts of self-harm *The nurse should determine whether the client has thoughts of self-harm following a sexual assault or other crisis situations. The nurse's priority is to ensure the client's safety.

A nurse is assisting with the admission of a client who has alcohol use disorder and is experiencing withdrawal. Which of the following actions is the nurse's priority? A. Pad the side rails of the client's bed B. Assign the client to a private room C. Collect a urine sample from the client D. Determine the client's level of disorientation

Determine the client's level of disorientation *The greatest risk to this client is self-injury from the alcohol withdrawal; therefore, the priority action the nurse should take is to determine the client's level of disorientation to ensure the client is safe from self-injury or harm

A nurse is planning care for a client who is experiencing complicated grief following the unexpected death of his partner. Which of the following actions should the nurse plan to take first? A. Positively reinforce new coping skills that increase the client's self-esteem B. Encourage the client to seek support from a counselor who specializes in grief C. Determine which stage of grief the client is experiencing D. Allow the client to express angry feelings associated with the grief

Determine which stage of grief the client is experiencing *The first action the nurse should take using the nursing process is to collect data to determine the stage of grief the client is fixed in to establish a baseline from which to plan care

A nurse is caring for a client with borderline personality disorder who has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following groups? A. Co-dependents support group B. National Alliance on Mental Illness C. Dialectical behavior treatment group D. Dual diagnosis treatment group

Dialectical behavior treatment group *The nurse should encourage the client to participate behavior treatment group that focuses on interventions for suicidal and destructive behaviors

A patient is taking lithium. For which symptoms will you monitor? A. Hypertension and headache B. Diarrhea and slurred speech C. Confusion and blurred vision D. Convulsion and polyuria

Diarrhea and slurred speech *Diarrhea and slurred speech are early signs of lithium toxicity. (1) Hypertension and headache are more closely associated with the MAOI antidepressants. Sodium depletion and dehydration may cause toxicity. (3, 4) Confusion, blurred vision, convulsion, and polyuria are late signs of lithium toxicity.

A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of the following medications should the nurse expect to administer during this phase of the client's care? A. Buprenorphine B. Diazepam C. Varenicline D. Rimonabant

Diazepam *The nurse should expect to administer diazepam to a client during alcohol detoxification. Anti-anxiety agents such as chlordiazepoxide and diazepam are long-acting CNS depressants that are used to minimize the manifestations of alcohol withdrawal

A nurse is contributing to the plan of care for a client who has alcohol use disorder. Which of the following medications should the nurse plan to administer? A. Methadone B. Varenicline C. Buprenorphine D. Diazepam

Diazepam *The nurse should plan to administer diazepam to this client who has alcohol use disorder to minimize manifestations of alcohol withdrawal.

A nurse is assisting with developing a plan of care for a client who has conversion disorder. Which of the following actions should the nurse include? A. Encourage the client to spend time alone in their room B. Monitor the client for self-harm once per day C. Allow the client unlimited time to discuss physical manifestations D. Discuss alternative coping strategies with the client

Discuss alternative coping strategies with the client *Discuss alternative coping strategies withthe client, Encourage the client to communicate with others and participate in group therapy and support groups, Continuously monitor the client for risk of self-harm, Establish a time limit for discussion of physical manifestations

A nurse is contributing to the plan of care for a client during the termination phase of the nurse-client relationship. Which of the following interventions should the nurse include? A. Discussing ways to use new behaviors B. Practicing new problem-solving skills C. Developing goals D. Establishing boundaries

Discussing ways to use new behaviors *Discussing ways for the client to incorporate new healthy behaviors is an appropriate task for the termination phase *Practicing new problem-solving skills is an appropriate task for the working phase *Developing goals is an appropraite task for the orientation phase *Establishing boundaries is an appropriate task for the orientation phase

A school nurse is providing care to a student who is angry and states, "My parents don't know I'm gay, so I can't visit my girlfriend in the hospital while she receives cancer treatment." Which of the following forms of grief is the client experiencing? A. Chronic grief B. Uncomplicated grief C. Disenfranchised grief D. Delayed grief

Disenfranchised grief *Disenfranchised grief occurs when social expectations restrict an individual's ability to cope with grief in an expected way. This type of grief can occur when the social relationship between the client and another individual who has an uncomplicated form of grief

A nurse is collecting data from a client who has brief psychotic disorder. Which of the following manifestations should the nurse expect? A. Evidence of self-mutilation B. Suicidal threats C. Disorganized speech D. Report of chronic depression

Disorganized speech *Clients who have brief psychotic disorder manifest confusion, disorganized speech, delusions, and hallucinations. The behavior can be brought on by a psychosocial stressor

A nurse is assisting with the admission of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? A. Reluctance to confide in others B. Doubting the trustworthiness of others C. Holding grudges against others D. Disregarding the safety of others

Disregarding the safety of others *A client who has antisocial personality disorder can disregard the safety of others. Other manifestation of this disorder can include deceitfulness, impulsiveness, and a lack of remorse

A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol? A. Chlordiazepoxide B. Buproprion C. Disulfiram D. Carbamazepine

Disulfiram *Expect to administer disulfiram to help the client maintain abstinence from alcohol *Chlordiazepoxide is indicated for acute alcohol withdrawal rather than to maintain abstinence from alcohol *Buproprion is indicated for nicotine withdrawal rather than to maintain abstinence from alcohol *Carbamazepine is indicated for acute alcohol withdrawal rather than to maintain abstinence from alcohol

A nurse in a rehabilitation unit is discharging a client who has alcohol use disorder. Which of the following prescriptions should the nurse anticipate for the client? A. Phenobarbital B. Disulfiram C. Varenicline D. Methadone

Disulfiram *The nurse should anticipate a prescription for disulfiram for a client who is in the maintenance phase of alcohol withdrawal. Disulfiram promotes refraining from alcohol through aversion therapy. Any intake of alcohol while the client is taking the medication will result in intense nausea and vomiting, headaches, respiratory difficulties, and confusion

A nurse is caring for a client who has alcohol use disorder. Following alcohol withdrawal, which of the following medications should the nurse expect to administer to the client during maintenance? A. Methadone B. Disulfiram C. Chlordiazepoxide D. Naloxone

Disulfiram *The nurse should expect to administer disulfiram as a deterrent to prevent future use of alcohol. The nurse must ensure the client has not had any alcohol intake for at least 12 hours prior to administration

A nurse is caring for a client with alcohol use disorder who has undergone detoxification. Which of the following medication should the nurse expect the provider to prescribe to assist the client in maintaining sobriety? A. Varenicline B. Clonidine C. Buprenorphone D. Disulfiram

Disulfiram *Disulfiram is a type of aversion therapy that helps clients abstain from alcohol. Drinking alcohol while taking this medication produces a toxic reaction that causes swelling, confusion, headaches, breathing difficulties, and other manifestations

A nurse is reinforcing teaching for a client who has generalized anxiety disorder and a new prescription for buspirone. The nurse should inform the client that which of the following manifestations is an adverse effect of this medication? A. Oliguria B. Tinnitus C. Dizziness D. Insomnia

Dizziness *The nurse should inform the client that dizziness is a common adverse effect of buspirone. The nurse should instruct the client to avoid driving and operating heavy machinery until the presence of adverse effects is determined

A nurse is collecting data from a client who has post-traumatic stress disorder (PTSD) due to a sexual assault that occurred 3 months ago. Which of the following findings should the nurse expect? A. Increased hours of sleep each day B. Repeatedly talking about the assault C. Dreaming about the assault D. Decreased responsiveness to stimuli

Dreaming about the assault *The nurse should expect the client who has PTSD to report recurring dreams about the assault

A nurse is reinforcing teaching with a client who has a prescription for lithium. Which of the following instructions should the nurse include in the teaching? A. Take this medication on an empty stomach B. Drink 2 L of fluid each day C. Use a salt substitute to season foods D. Take ibuprofen for headaches

Drink 2 L of fluid each day *The nurse should instruct the client to drink at least 2 to 3 L of fluid per day to remain hydrated and to consume a consistent amount of sodium. Low sodium levels can result in lithium toxicity

A nurse is reinforcing teaching with the partner of a client who has a new diagnosis of bipolar disorder. Which of the following behaviors should the nurse describe as a trigger for a relapse of mania? A. Using a daily planner B. Sleeping too much C. Eating too much protein D. Drinking alcohol

Drinking alcohol *The use of alcohol, caffeine, some over-the-counter medications, and some substances can trigger a relapse

A nurse is assisting with planning care for a client who has major depression and a new prescription for amitriptyline. The nurse should plan to monitor the client for which of the following adverse effects? A. Hypertension B. Drowsiness C. Panic attacks D. Diarrhea

Drowsiness *Drowsiness is an expected side effect of amitriptyline and other tricyclic antidepressants. Sedation will likely be present during the first few weeks of treatment with amitriptyline and put the client at risk for falls

A nurse is administering alprazolam for the first time to a client who has anxiety. The nurse should monitor the client for which of the following adverse effects of this medication? A. Tinnitus B. Elevated blood pressure C. Drowsiness D. Bleeding gums

Drowsiness *The nurse should be aware that alprazolam, a benzodiazepine, commonly causes CNS depression, including drowsiness. When administering this medication to a client for the first time, the nurse should monitor the client for drowsiness and implement interventions to reduce the risk of falls or injury

A nurse is reinforcing teaching with an adolescent clietn who has a new prescription for clomipramine for OCD. Which of the following information should the nurse provide? A. Eat a diet high in fiber B. Check temperature daily C. Take medication first think in the morning before eating D. Add extra calories to the diet as between-meal snacks

Eat a diet high in fiber *Eating a diet high in fiber will decrease constipation, an anticholinergic effect associated with TCA use *Checking the client's temperature daily is not necessary while taking a TCA *Taking the medication at bedtime rather than in the morning will prevent daytime sleepiness *Following a well-balanced diet rather than adding extra calories as snacks will help prevent weight gain, a common adverse effect of TCAs

A nurse is reviewing the laboratory report of a client who is taking risperidone. The nurse should identify that which of the following result indicates a potential adverse reaction to the medication? A. Elevated blood glucose B. Elevated WBC count C. Decreased platelet count D. Decreased aspartate transaminase (AST)

Elevated blood glucose *The nurse should identify that all second-generation antipsychotic medications such as risperidone can cause diabetes, weight gain, and dyslipidemia. To monitor for diabetes, a baseline glucose reading should be obtained and compared to a glucose reading taken 12 weeks later. If there is no change after 12 weeks, glucose should be monitored annually

A nurse is collecting data from a client who takes an MAOI for the treatment of depression. Which of the following findings is the priority for the nurse to report to the provider? A. Elevated blood pressure B. Weight gain C. Muscle twitching D. 2+ peripheral edema

Elevated blood pressure *The greatest risk to the client is an elevated blood pressure, which increased the risk of a hypertensive crisis that can result from taking an MAOI.

A nurse is monitoring a client who has schizophrenia and is receiving treatment with fluphenazine hydrochloride. Which of the following findings is an indication of neuroleptic malignant syndrome that the nurse should report to the provider? A. Blurred vision B. Urinary retention C. Muscle flaccidity D. Elevated temperature

Elevated temperature *Elevated temperature is a manifestation of neuroleptic malignant syndrome that should be immediately reported to the provider. Other symptoms of the syndrome include rigidity, sweating, dysrhythmias, and fluctuations in blood pressure

The nurse differentiates vascular dementia from Alzheimer dementia. Which causative factor is responsible for vascular dementia? A. Cerebral atrophy B. Global reduction of cognition C. Hypertension D. Emboli in cerebral vessels

Emboli in cerebral vessels *Vascular dementia occurs from brain tissue becoming hypoxic and necrotic in local areas due to small emoboli. The deficits may be intellectual or loss of sensory function

A nurse is planning care for a client who has dissociative disorder and is experiencing flashbacks while in public. Which of the following interventions should the nurse include in the plan to help the client recognize and counter the flashbacks? A. Encourage reality testing B. Provide opportunities for socialization C. Consistently remind the client of past traumatic events D. Discourage client expressions of negative feelings

Encourage reality testing *Reality testing involves scanning the surrounding to see if others are afraid and reorientations to time and place. This can help clients recognize that the flashbacks are not real

A nurse is contributing to the plan of care for a client with bipolar disorder who has acute mania. Which of the following interventions should the nurse recommend including in the plan? A. Provide the client with a low-calorie, low-fat diet B. Encourage the client to have frequent rest periods C. Escort the client to daily group therapy D. Limit the client's intake of caffeinated beverages to 12 oz per day

Encourage the client to have frequent rest periods *The nurse should recommend encouraging frequent rest periods throughout the day to decrease the client's risk of exhaustion from the constant activity associated with acute mania.

A nurse is planning care for a newly admitted client who has post-traumatic stress disorder (PTSD). Which of the following interventions should the nurse recommend for this client? A. Rotate staff assignments for the client B. Refrain from discussing the client's maladaptive coping strategies C. Wait for the client to initiate interactions with staff members D. Encourage the client to participate in group therapy

Encourage the client to participate in group therapy *Clients who have PTSD can benefit from group therapy. Sharing with others who have the same experiences has been effective therapy

A nurse on an acute mental health unit is caring for a client who is experiencing a manic episode with agitation. Which of the following actions should the nurse take? A. Schedule the client for group therapy B. Discourage the client from napping during the day C. Encourage the client to participate in physical activity D. Allow the client to spend time alone

Encourage the client to participate in physical activity *Offering the client who is experiencing a manic episode an opportunity for physical activity can decrease stress and provide an outlet for the client's excessive energy and agitation

A nurse on a mental health unit is caring for a client who has social anxiety disorder and is exhibiting signs of panic. Which of the following actions should the nurse take to reduce the client's level of anxiety? A. Accompany the client to an area with increased environmental stimuli B. Suggest that the client lies down and rests C. Place the client in seclusion D. Encourage the client to practice deep breathing

Encourage the client to practice deep breathing *The nurse should encourage the client to practice slow deep-breathing exercises to elicit relaxation. The nurse should demonstrate the technique and practice it along with the client. Focus on taking slow, deep breaths can help divert the client's attention from feelings of anxiety

A nurse is caring for a client who has schizophrenia and is experiencing auditory and visual hallucinations. Which of the following actions should the nurse take? A. Ask the client what the voices are saying B. Encourage the client to use reality testing C. Limit the client's exposure to noise D. Place the client in seclusion

Encourage the client to use reality testing *A client who is experiencing hallucinations can become frightened or agitated. The nurse should encourage the client to perform reality testing during periods of hallucinations by looking at the faces of other clients in the area. If the other clients do not appear frightened, the client should identify that the perception is a hallucination and not real.

A nurse is caring for a child who has a diagnosis of terminal brain cancer. The mother states, "I feel numb and can't believe this is happening to us." Which of the following interventions is the nurse's priority? A. Explore effective ways of family coping B. Encourage the family's expression of their feelings C. Discuss the disease and its manifestations with family members D. Instruct the family about anticipatory grieving

Encourage the family's expression of their feelings *The first action the nurse should take using the nursing process is to assess the family by encouraging them to express their feelings about their child's illness. This assessment will allow the nurse to understand the particular needs of the family better as they prepare to face their child's death

A nurse is caring for a client who has antisocial personality disorder. Which of the following actions should the nurse take? A. Encourage the client to attend assertive behavior sessions B. Ensure staff members set limits on the client's behavior C. Tell the client to socialize more with other clients on the unit D. Frequently implement measures to increase the client's self-esteem

Ensure staff members set limits on the client's behavior *The nurse should ensure all staff members set limits on the client's behavior. The limits should be clear and realistic and realistic and address specific behaviors. Also, the nurse should provide clear boundaries and consequences for the client

A patient is admitted after abusing an inhalant. Which safety precaution is most important for the nurse to take? A. Check the patient's temperature hourly B. Place the patient on seizure precautions C. Monitor carefully for changes in urine output D. Ensure that respiratory support equipment is present at the bedside

Ensure that respiratory support equipment is present at the bedside *Medical treatment and intervention for both hallucinogens and inhalants include provision of safety for the individual who may be experiencing a bad "trip." Emergency measures may be necessary to provide respiratory support for an individual who has impaired gas exchange as a result of inhalants

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse contribute to the plan of care? A. Assign the client to a private room B. Document the client's behavior every hour C. Allow the client to keep perfume in their room D. Ensure that the client swallows medication

Ensure that the client swallows medication *Ensure that the client swallows medication to prevent hoarding of medication for an attempt to exceed the prescribed dose *Clients who are suicidal should not be assigned a private room *Client's behavior should be documented every 15 min or according to facility policy *Remove perfume from the client's room

The patient was given an SSRI about 60 minutes ago and is now having change of mental status, a rapid pulse, loss of muscular coordination, and hyperthermia. Which action should the nurse take first to address this life-threatening condition? A. Ensure that there is a patent IV access B. Initiate seizure precautions C. Obtain an order for anxiolytic medication D. Prepare the emergency respiratory equipment

Ensure that there is a patent IV access

A nurse is contributing to the plan of care for a client who has borderline personality disorder and exhibits manipulative behaviors. Which of the following interventions should the nurse include to address limit-setting? A. Instruct the client to use reaction formation for behavior control B. Recommend the client attend assertiveness training C. Establish and explain consequences of the client's behavior D. Encourage the client to increase socialization

Establish and explain consequences of the client's behavior *The nurse should communicate desired behavior and expectations to the client, as well as the detailed consequences of not meeting them. When addressing limit-setting with the client, these expectations and consequences should be included in the plan of care

A community mental health nurse is assisting with the plannin of care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse recommend the RN implement as a method of tertiary prevention? A. Educate clients on health promotion techniques to reduce the risk of depression B. Perform screenings for depression at community health problems C. Establish rehabilitation programs to decrease theeffecets of depression D. Provide support groups for clients at risk for depression

Establish rehabilitation programs to decrease theeffecets of depression *Rehabilitation programs are an example of tertiary prevention. Tertiary prevention deals with prevention of further problems in clients already diagnosed with mental illness *(A) This intervention is an example of primary prevention *(B) This interventio is an example of secondary prevention *(D) This intervention is an example of primary prevention

The nurse is aware that interventions for the negative symptoms of schizophrenia are based on which factor? A. Establishment of trust B. Acceptance of medication protocols C. Support in interpersonal social activities D. Promotion of conversation with the patient

Establishment of trust *General nursing interventions for the negative symptoms include establishing trust and teaching the patient and family how to manage the signs and symptoms. An attitude of acceptance is necessary to promote trust

A nurse is collecting data from a client who has a history of methamphetamine use. Which of the following findings indicates that the client is currently under the influence of this drug? A. Paranoia B. Slurred speech C. Marked lethargy D. Bradycardia

Paranoia *Acute effects of methamphetamine use include increased heart rate and metabolism, mental alertness, reduced appetite, and paranoia

Which action is most important for the nurse to take before providing care for substance abusers? A. Become familiar with self-help programs B. Examine personal bias relative to substance abuse C. Become knowledgeable about theories of addiction D. Ensure consistency with each patient

Examine personal bias relative to substance abuse *Nurses must first determine their own biases and attitude toward substance abuse and substance abusers before they can relate effectively with the patient. Familiarization with resources and knowledge about theories of addiction are tools of lesser importance

A nurse is assisting with an educational seminar on stress for other nursing staff. Which of the following information should the nurse recommend for inclusion? A. Excessive stressors cause the client to experience distress B. The body's initial adaptive response to stress is denial C. Absence of stressors results in homeostasis D. Negative, rather than positive, stressors produce a biological response

Excessive stressors cause the client to experience distress *Distress is the result of excessive or damaging stressors (anxiety or anger) *Denial is part of the grief process. The body's initial adaptive reponse to stress is known as the fight-orflight mechanism *Individuals need the presence of some stressors to provide interest and purpose to life *Both positive and negative stressors produce a biological reponse in the body

A nurse in a provider's office is reinforcing teaching with a client who is experiencing stress due to the loss of a job. Which of the following instructions should the nurse give? A. Drink no more than 6 cups of coffee per day B. Exercise for 140 minutes each week C. Get 6 hours of sleep every night D. Sleep 30 minutes later each morning

Exercise for 140 minutes each week *The nurse should instruct the client to exercise for 140 minutes per week, or 20 min per day, by participating in moderate-intensity aerobic activities such as walking. Exercise can reduce stress and increase endorphin levels

A nurse is reestablishing a therapeutic relationship with a client. Which of the following actions should the nurse perform during the orientation phase of the the relationship? A. Research the client's condition B. Explain confidentiality to the client C. Provide the client with information about her disorder D. Summarize the client's goals

Explain confidentiality to the client *The nurse should explain confidentiality to the client during the orientation phase of the therapeutic relationship. Other tasks the nurse should accomplish during this phase include establishing a rapport and specifying a contract containing the date, time, and place of future meetings with the client

A nurse is caring for a client with borderline personality disorder (BPD) who exhibits a pattern of playing staff members against each other. Which of the following actions should the nurse take? A. Have the same staff members work with the client on a long-term basis B. Listen to the client when he reports feelings about other staff members C. Explore the client's use of clinging and distancing behaviors with him D. Arrange for the client to share complaints with the nursing supervisor

Explore the client's use of clinging and distancing behaviors with him *Splitting is a common defense mechanism demonstrated by clients who have BPD in which the client plays staff members against each other. First, the client expresses feelings of attachment toward a certain staff member and then abruptly begins issuing complaints about this person to other staff members. The underlying cause of splitting is a fear of abandonment and an inability to accept both positive and negative feelings. Therefore, the client demonstrates only negative or positive feelings toward others

A patient with schizophrenia is receiving clozapine 150 mg twice a day. The nurse knows to be vigilant for which sign of an adverse effect of this drug? A. Elevated blood pressure (BP) B. Weight gain C. Photosensitivity D. Extreme temperature elevations

Extreme temperature elevations *Known as neuroleptic malignant syndrome, this is an adverse reaction to antipsychotics characterized by extreme elevations in body temperature. Elevations in BP are associated with interactions between foods containing tyramine and monoamine oxidase inhibitor. Weight gain and photosensitivity are common side effects of many antipsychotics and do not necessarily represent adverse effects.

A nurse is preparing to meet with a client who has borderline personality disorder. Which of the following actions should the nurse plan to take during the working phase of the therapeutic relationship? A. Introduce the concept of client confidentiality B. Establish goals with the client C. Define the roles of the nurse and the client D. Facilitate change in the client's behavior

Facilitate change in the client's behavior *The nurse should facilitate change in the client's behavior during the working phase of the therapeutic relationship.

A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts? A. Invasion of privacy B. False imprisonment C. Assault D. Battery

False imprisonment *A civil wrong that violates a client's civil rights is a tort. In this case, it is false imprisonment, which is the confining of a client to a specific area (a seclusion room) if the reason for such confinement is for the convenience of staff.

A nurse is reinforcing teaching with a client who has schizophrenia and a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider immediately? A. Constipation B. Fever C. Weight gain D. Dry eyes

Fever *When using the urgent vs non-urgent approach to client care, the nurse should recognize that the priority adverse effect that should be reported to the provider when taking haloperidol is flu-like manifestations such as fever, a sore throat, fatigue, and muscle stiffness. These manifestations may indicate neuroleptic malignant syndrome, which is a life-threatening reaction to some antipsychotic medications

A student nurse questions the nurse about the frequency of administration of antipsychotics, such as risperidone (Risperdal). Which advantage is true of newer antipsychotics like risperidone (Risperidone)? A. Decreased photosensitivity B. Fewer serious side effects C. Less expensive D. Decreased incidence of headaches

Fewer serious side effects *Risperidone (Risperdal) is a newer generation of "atypical" antipsychotic medications that is known for having fewer serious side effects, such as tardive dyskinesia, but they still have significant effects

A military veteran is admitted to your unit with a diagnosis of chronic post-traumatic stress disorder (PTSD). After being placed in the treatment room, he begins to pace frantically and make references to "Highway 1." As the nurse approaches him, he retreats to the corner and sits on the floor with his arms and legs pulled tightly to his body. This patient is most likely experiencing which occurrence? A. Flashback B. Hallucination C. Phobic reaction D. Delusion

Flashback *This patient's symptoms are consistent with a flashback secondary to PTSD. Hallucinations and delusions are associated with psychotic disorders such as schizophrenia. Phobic reactions are not associated with the symptoms this patient is exhibiting.

A nurse on a mental health unit is preparing to discharge a client who has bulimia nervosa. Which of the medications should the nurse expect the provider to prescribe for the client? A. Paroxetine B. Fluconazole C. Bupropion D. Fluoxetine

Fluoxetine *The nurse should expect the provider to prescribe fluoxetine for a client who has bulimia nervosa. It is an SSRI used most frequently for the treatment of depression. It is thought to assist in the treatment of binge eating associated with bulimia by decreasing the craving for carbohydrates. It is prescribed for bulimia at 3 times the dosage that is used for the treatment of depression

A nurse is assisting with preparing an in-service session about Alzheimer's disease for a group of newly licensed nurses. Which of the following findings should the nurse include as an early manifestation in the progression of the disease? A. Forgetting material that was just read B. Losing the ability to feel emotions C. Experiencing changes in physical abilities such as swallowing D. Having difficulty controlling the bladder

Forgetting material that was just read *Forgetting material that has just been read is a sign of mild Alzheimer's and is an early manifestation of the disease. Mild memory impairment includes recent memory. Gradually, deterioration progresses to include both recent and remote memory

A nurse in an assisted living facility is collecting data on an older adult client. Which of the following findings should the nurse identify as expected age-related changes? A. Forgetting the days of the week B. Challenges with problem-solving C. Decreased judgment D. Withdrawal from social activities

Forgetting the days of the week *The nurse should identify that forgetting the day of the week and remembering it later is an expected age-related change in older adult clients. Other findings can include needing assistance when operating devices such as a microwave, making occasional errors when balancing a checkbook, having difficulty finding the correct use of a word, and becoming tired after family gatherings or social activities

The nurse is concerned about a coworker who she suspects is abusing amphetamines. Which behavior best validates the nurse's concern? A. Frantic, excited speech B. Poor attention to detail C. Poor personal hygiene D. Insatiable hunger

Frantic, excited speech *Excited speech, euphoric behavior, increased alertness, and anorexia are indications of abuse of amphetamines

Memory lapses seen in early stages of Alzheimer's disease (AD) are related to pathophysiology of which condition? A. Frontal lobe atrophy B. Overproduction of neurotransmitters C. Pituitary disorders D. Inadequate clearance of metabolic toxins

Frontal lobe atrophy *Loss of neurons in the frontal and temporal lobes results in atrophy and the many signs of AD, memory deficits being one of the earliest

A patient with Alzheimer disease (AD) has been prescribed oral donepezil 10 mg. The nurse should give priority to assessing the patient for which sign of an adverse effect of this drug? A. Skin rashes B. Cardiac dysrhythmias C. Decreased blood pressure D. Gastrointestinal (GI) bleeding

Gastrointestinal (GI) bleeding *Patients receiving donepezil should be monitored for active or occult GI bleeding. Although patients should be assessed for all of these, especially when beginning a new medication, dysrhythmias, rashes, and decreased blood pressure are not associated with donepezil use.

A nurse is planning care for a newly admitted child who has autism spectrum disorder. Which of the following actions should the nurse nurse include in the plan of care? A. Avoid making eye contact with the child B. Rotate staff assignments for the child C. Offer frequent acts of physical affection towards the child D. Give the child a favorite toy to hold

Give the child a favorite toy to hold *The nurse should provide the child with a familiar object such as a favorite toy or a blanket to foster a sense of comfort and security

A nurse in an acute care mental health facility observes a client who has bipolar disorder to begin to shout and use offensive language toward a visitor. Which of the following actions should the nurse take? A. Give the client 2 options for ending the situation B. Move quickly to stand directly in front of the client before speaking C. Direct other clients to move toward the client as a show of force D. Tell the client that the conversation will be ended if the shouting continues

Give the client 2 options for ending the situation *Giving the client several options (e.g. 2 different location in which to be away from visitors and other clients) prevents the client from feeling powerless and gives the client some responsibility for making choices

A nurse is collecting data from a client who reports being abused by his partner. Which of the following actions should the nurse take? A. Tell the client that he is morally obligated to press charges against his partner B. Inform the client that photographs of his injuries must be taken C. Tell the client that he will be taken to a safe house D. Give the client a detailed explanation of all of the procedures that must be performed

Give the client a detailed explanation of all of the procedures that must be performed *A client who reports abuse will often experience fear and anxiety. Providing sensitive and supportive care by explaining all procedures and providing privacy for the client can decrease the client's anxiety and feelings of vulnerability

A nurse on an inpatient mental health unit is caring for a client who is angry and showing signs of potential violence. Which of the following actions should the nurse take to de-escalate the client's anger? A. Call security personnel for a show of force B. Inform the client that restraints will be used as a consequence for verbal abuse C. Speak to the client in a loud, forceful voice D. Give the client extra personal space

Give the client extra personal space *A client who is experiencing escalating anger requires additional space to feel less threatened. The nurse should stand 1 foot farther away from the client than the client's arms and legs can reach

A nurse is collecting data from a client who was recently admitted following a suicide attempt. Which of the following behaviors is the priority for the nurse to report to the adolescent's treatment team? A. Calling family members B. Spending time alone C. Giving away possessions D. Excessive crying

Giving away possessions *Giving away possessions indicates that this adolescent client is a the greatest risk for suicide. The nurse should have a relationship built on trust an respect so that the nurse feels comfortable enough to ask the adolescent directly about suicidal thoughts and/or plans. Therefore, this is the priority finding for the nurse to report to the treatment team

A nurse is assisting with systematic desensitication for a client who has an extreme fear of elevators. Which of the following actions should the nurse implement with this form of therapy? A. Demonstrate riding in an elevator, and then ask the client to imitate the behavior. B. Advise the client to say "stop" out loud every time they begin to feel an anxiety response related to an elevator C. Gradually expose the client to an elevator while practicing relaxation techniques D Stay with the client in an elevator until the anxiety reponse diminishes

Gradually expose the client to an elevator while practicing relaxation techniques *Systemiatic desensitization is the planned, progressive exposure to anxiety-provoking stimuli. During this exposure, relaxation techniques suppress the anxiety responses *Demonstration followed by client imitation of the behavior is an example of modeling *Instructing a client to say "stop" when anxiety occurs is an example of thought stopping *Exposing the client to a great deal of an undesirable stimulus in an attempt to turn off the anxiety response is an example of flooding

The patient confides in the nurse he would like help in controlling his drinking. The nurse should recommend which of the following types of therapy, shown to be most effective at helping patients quit drinking? A. Group support, such as Alcoholics Anonymous (AA) B. Drug therapy, especially aversive therapy with disulfiram C. Reduction of, but not elimination of, alcohol consumption D. Electroconvulsive therapy (ECT)

Group support, such as Alcoholics Anonymous (AA) *Group support, such as AA, is one of the most effective treatments for alcoholism. ECT is not a treatment for alcoholism. Drugs may be used to manage acute withdrawal but are not consistently successful long-term therapy. Reducing alcohol consumption is not successful for most individuals with alcoholism.

The nurse uses the CAGE challendge to alcoholics who persist in denial. What does the "G" in the set of questions frmo CAGE represent? A. Get: "Do you feel like you must get alcohol?" B. Go: "Do you go out to drink?" C. Gone: "Is memory of drinking episodes gone?" D. Guilty: "Do you feel guilty about your drinking?"

Guilty: "Do you feel guilty about your drinking?" *A commonly used screening tool for alcohol abuse is the CAGE assessment. Two of more "Yes" answers have a 90% correlation with an alcohol abuse problem. The "G" stands as a reminder for the question, "DO you feel guilty about your drinking."

A nurse is collecting data from a client who was brought to the emergency department by a friend. The friend reports that the client inhaled a large amount of cocaine. Which of the following findings should the nurse expect? A. Depressed mood B. Hallucinations C. Severe hypotension D. Bradycardia

Hallucinations *Cocaine is central nervous stimulant; therefore, the nurse should expect this client with cocaine intoxication to have hallucinations and delirium. Other manifestations of cocaine intoxication include grandiosity, euphoria, elevated blood pressure, tachycardia, and dilated pupils

A nurse is collecting data from a client who has a history of alcohol use disorder and is experiencing alcohol withdrawal. Which of the following findings should the nurse identify as a manifestation of severe alcohol withdrawal? A. Decreased appetite B. Slurred speech C. Insomnia D. Hallucinations

Hallucinations *Hallucinations are a manifestation of severe alcohol withdrawal. Other manifestations of severe alcohol withdrawal include diaphoresis, hyperthermia, and tachycardia

A nurse is assisting with the admission of a client who has schizophrenia. During the initial interview, which of the following behaviors should the nurse identify as a positive manifestation of schizophrenia? A. Anhedonia B. Avolition C. Flat affect D. Hallucinations

Hallucinations *Positive manifestations of schizophrenia include behaviors or thought patterns that are not usually present. Hallucinations are a positive manifestation of schizophrenia. Other positive manifestations are religiosity, delusions, paranoia, and disorganized speech

A nurse is collecting data from a client who was diagnosed with schizophrenia. The nurse should identify that which of the following findings is considered a positive symptom of schizophrenia? A. Hallucinations B. Social withdrawal C. Anergia D. Flat effect

Hallucinations *Positive symptoms fall into the following categories: content of thought, form of thought, perception, or sense of self. The nurse should identify that hallucinations fall under the category of perception and cause the client to experience sensory perceptions that are not associated with reality. Other positive symptoms include delusions, depersonalization, and concrete thinking

A nurse is caring for a client who has been taking fluoxetine for anxiety. Which of the following adverse effects of this medication should the nurse report to the provider immediately? A. Mydriasis B. Hallucinations C. Arthralgia D. Sexual dysfunction

Hallucinations *The nurse should identify that hallucinations can be an adverse effect of fluoxetine and can also indicate that the client is experiencing serotonin syndrome. Serotonin syndrome can be caused by too high a dose of fluoxetine or an interaction with another medication. Other adverse effects of serotonin syndrome can include diarrhea, sweating, fevers, tachycardia, abdominal pain, and increased blood pressure. The nurse should notify the provider immediately

A patient taking antipsychotic medications develops a flat affect with drooling, a shuffling gait, and tremors. You would look for a health care provider order in the MAR for which medication? A. Benztropine (Cogentin) B. Haloperidol (Haldol) C. Amantadine (Symmetrel) D. Trihexyphenidyl (Artane)

Haloperidol (Haldol) *The patient is manifesting symptoms of pseudoparkinsonism, which may be caused by haloperidol (Haldol). Treatment of these symptoms involves anticholinergic medications such as (1) benztropine (Cogentin) or antiparkinsonian agents such as (3) amantadine (Symmetrel) or (4) trihexyphenidyl (Artane).

A 53-year-old female is diagnosed with generalized anxiety disorder. Which behavior do you anticipate? A. Runs out of the room when she notices a spider in the corner B. Continuously checks to see if doors are shut and locked C. Has difficulty concentrating and excessively worries about her family D. Wakes at night screaming because of recurrent nightmares

Has difficulty concentrating and excessively worries about her family *Difficulty concentrating and excessive worry are part of the diagnostic criteria for general anxiety disorder (GAD). (1) Excessive fear of spiders is an example of phobic disorder. (2) Repetitive checking and rechecking doors is an example of behavior associated with obsessive-compulsive disorder. (4) Recurrent nightmares are associated with post-traumatic stress disorder (PTSD).

You identify which patient behavior as indicative of mild Alzheimer disease? A. Has difficulty swallowing during meals B. Needs repeated instructions for simple tasks C. Has difficulty learning new things D. Cannot recognize familiar people

Has difficulty learning new things *Having difficulty learning new things is common in the early stages of Alzheimer disease. (1) Difficulty swallowing is a sign in late Alzheimer disease. (2) Needing repeated instructions for simple tasks is characteristic of moderate Alzheimer disease. (4) Inability to recognize familiar people is a sign of late Alzheimer disease.

You are administering medication to a familiar patient who has been on the unit for several weeks. When you ask, "What is your name?". the patient replies, "I am Jesus Christ, the Son of God." What is the appropriate nursing action? A. Give the medication because you know the patient is confused. B. Document that the patient cannot verify identity and hold the medication C. Hold the medication until the family can bring in a picture identification D. Have a second nurse verify the patient's identity and document accordingly

Have a second nurse verify the patient's identity and document accordingly *Having another health care provider verify the patient's identification is the best option, so that the patient can continue to receive the medication. (1) If you give a medication without validating the patient's identity, there is the possibility of medication error. (2, 3) Holding the medication is not in the best interests of the patient; however, it would be worthwhile for the staff to develop an alternative identification process for confused patients, and pictures could be used. Verification of the patient ID band against the electronic health record and scanning the patient ID are other ways of validating the patient's identity.

A nurse is assessing a 6-year-old child who began treatment for pneumococcal pneumonia 4 days ago. Which of the following findings should the nurse identify as an indication the treatment is effective? A. Dullness with chest percussion B. Heart rate 118/min C. Conjunctival discharge D. Respiratory rate 28/min

Heart rate 118/min *The nurse should identify that a heart rate of 118/min is within the expected reference range for a 6-year-old child. A child who has an acute pneumococcal pneumonia infection will exhibit tachycardia

A nurse is caring for a client who presents with a fractured wrist. The nurse suspects intimate partner violence. Which of the following interventions is the nurse's priority? A. Help the client develop a safety plan B. Teach the client empowerment skills C. Provide information about a support group for intimate partner abuse D. Make a follow-up appointment with the primary provider

Help the client develop a safety plan *The greatest risk to this client is further injury from the partner; therefore, the priority intervention for the nurse is to help the client develop a safety plan for a rapid escape if further violence occurs

A patient is in the early recovery process and is attempting to lead a drug-free life. Which nursing intervention is the most appropriate? A. Remind the patient of the discomfort and pain that occurred during detoxification B. Tell the patient that there is no need to feel guilty or ashamed C. Help the patient to identify relationships that were part of the substance use pattern D. Advise the patient that stopping forever is the only choice for a drug-free life

Help the patient to identify relationships that were part of the substance use pattern *Identifying relationships that were part of the substance use pattern will help the patient avoid going back into the same circumstances. (1) The patient is already acutely aware of the physical experience of withdrawal. (2) Dealing with guilt and shame is part of the recovery process. You should not give the patient absolution for past behaviors. (4) The patient is likely to be intellectually aware of the need for a drug-free life; repeating this is not helpful.

A nurse is reviewing the plan of care for a client who has bipolar disorder. Which of the following is an effect of using cognitive behavioral therapy (CBT) for a client who has bipolar disorder? A. Prevents the need for mood-stabilizing medications B. Helps the client deal with distorted thought processes C. Aids in communication among family members D. Replaces the need for lifestyle interventions

Helps the client deal with distorted thought processes *CBT assists the client with recognizing distorted thought processes that are maladaptive with regards to recovery. When experiencing mania, the client tends to view the future unrealistically as highly favorable. CBT assists the client in recognizing and challenging such unrealistic or "automatic" thoughts and can help the client and the health care team recognize early trends toward mania

A nurse is caring for a client who has bipolar disorder. Which of the following manifestations is the priority finding for the nurse to identify? A. Inability to concentrate B. Poor hygiene C. Hyperactivity D. Pressured speech

Hyperactivity *The greatest risk to this client is an injury from hyperactivity; therefore, the priority finding for the nurse to identify is hyperactivity. The nurse should intervene to redirect the client from unsafe activities. Constant activity can lead to exhaustion and even death

A nurse is assisting with the admission of a client who has opioid use disorder. Which of the following manifestations should indicate to the nurse that the client is experiencing opioid withdrawal? A. Hypertension B. Sedation C. Hypothermia D. Bradycardia

Hypertension *The nurse should identify that hypertension is a manifestation of opioid withdrawal. Other manifestations of opioid withdrawal can include tachycardia, enlarged pupils, increased body temperature, tachypnea, diaphoresis, rhinorrhea, anxiety, muscle spasms, nausea and vomiting, and abdominal cramping

A nurse in an urgent care clinic is collecting data from a client who reports recent cocaine use. Which of the following manifestations should the nurse expect? A. Hypertension B. Drowsiness C. Bradycardia D. Pinpoint pupils

Hypertension Cocaine is a central nervous system stimulant. Therefore, hypertension is an expected finding in a client who has recently used cocaine

A nurse is reviewing the medical record of a client who has a new prescription for a benzodiazepine. For which of the following findings should the nurse question the provider's prescription? A. Skeletal muscle injury B. History of status epilepticus C. Hypotension D. Insomnia

Hypotension *The nurse should question the provider's prescription for a benzodiazepine. Benzodiazepine can cause severe hypotension and increase the client's risk for cardiac arrest

A nurse is assisting with providing care for a client who has benzodiazepine toxicity. Which of the following actions is the nurse's priority? A. Administer flumazenil B. Idenitify the client's level of orientation C. Ensure the administration of IV fluids D. Prepare the client for gastric lavage

Idenitify the client's level of orientation *When taking the nursing process approach to client care, the intial step is data collection. Identifying the client's level of orientation is the priority action *Administer flumazenil will reverse the effects of benzodiaxepine, ensure the administration of IV fluids to maintain blood pressure, and gastric lavage will remove excessive medication from the client's GI system; however, another action is the priority

A nurse is assisting with instructing a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? A. Personal space B. Posture C. Eye contact D. Intonation

Intonation *Identify intonation as a component of verbal communication. Intonation is the tone of one's voice and can communicate a variety of feelings *Personal space, posture, and eye contacts are components of nonverbal communication

A nurse in a mental health facility is planning to promote the development of a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take? A. Begin each interaction by sharing a personal story B. Identify professional boundaries during the initial interaction C. Agree with the client's perceptions and emotions to encourage free expression D. Allow the client to meet with the nurse at any time during the day

Identify professional boundaries during the initial interaction *The nurse should promote a therapeutic nurse-client relationship by identifying distinct boundaries with the client. These boundaries help promote a therapeutic nurse-client relationship, rather than a social nurse-client relationship

A nurse is preparing to care for a client who was brought to a community health facility by her caregiver, who states that the client refuses to eat. The nurse notes the client has lost weight, avoids making eye contact, and defers questions to the caregiver. Which of the following actions should the nurse take? A. Make sure the caregiver is present when interviewing the client B. Document how the caregiver responds when told that the client looks neglected C. Ask the client why she refuses to eat the caregiver's food D. Identify sources of stress for the caregiver

Identify sources of stress for the caregiver

A nurse in an outpatient mental health clinic is preparing to assist with an initial interview. When conducting the interview, which of the following actions should the nurse identify as the priority? A. Coordinate holistic care with social services B. Identify the client's perception of their mental health status C. Include the client's family in the interview D. Instruct the client about their current mental health disorder

Identify the client's perception of their mental health status *Data collections is the priority action when using the nursing process approach to client care. Identifying the client's perception of their mental health status provides important information about the client's psychosocal history *It is appropriate to coordinate holistic care for the client with social services as part of case management. However, another action is the priority *If the client wishes, it is appropriate to include the client's family in the interview. However, another action is the priority *It is appropriate to instruct the client about their disorder. However, another action is the priority

A nurse is collecting data from a client who has oppositional defiant disorder. Which of the following findings should the nurse expect? A. Flat affect B. Unmotivated by rewards C. Ignoring unit rules D. Fearing a loss of privileges

Ignoring unit rules *The nurse should expect a client who has oppositional defiant disorder to ignore and break rules or requests from those in positions of authority

The patient is suffering acute delirium related to a systemic infection. During the evening, the patient appears to be very frightened by the IV tubing. The nurse recognizes that the patient might be experiencing which disturbance? A. Hallucination B. Illusion C. Delusion D. Confabulation

Illusion

A nurse is collecting data from a client who is at risk for cognitive impairment. Which of the following findings should the nurse identify as an early indication of cognitive decline? A. Disorientation to time B. Problems handling finances C. Social withdrawal D. Impaired recent memory

Impaired recent memory *Short-term memory loss is generally an early indication of mild cognitive decline. Other indications of early or mild dementia include misplacing household items and demonstrating subtle changes in personality

A nurse is contributing to the plan of care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following interventions should the nurse include? A. Allow the client to select preferred meal times B. Establish consequences for purging behavior C. Provide the client with a high-fat diet at the start of treatment D. Implement one-to-one observation during meal times

Implement one-to-one observation during meal times *Closely monitor the client during and after meals to prevent purging *Provide a highly structured milieu, including meal times, for the client requiring acute care for the treatment of anorexia nervosa *Use a positive approach to client care that includes rewards rather than consequences *Limit high-fat and gas-producing foods at the start of treatment

A nurse is contributing to the plan of care of a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority? A. Orient the client frequently to time, place, and person B. Offer fluids and nourishing diet as tolerated C. Implement seizure precautions D. Encourage participation in group therapy sessions

Implement seizure precautions *The greatest risk to the client is injury. Implementing seizure precautions is the priority intervention *The other 3 are appropriate interventions but are not the highest priority

A client who has hypertension presents to a provider's office. When speaking with the nurse, she reports a considerable amount of stress at work and states it is affecting her blood-pressure control. The nurse should instruct the client to do which of the following when the stress is unavoidable? A. Consider changing jobs to something less stressful B. Identify the stressors at work and try to reduce them C. Plan periods away from work throughout the day D. Improve her ability to cope with identified stressors

Improve her ability to cope with identified stressors *The nurse should help the client learn management techniques to deal with stress without internalizing it

A nurse is caring for a client who has schizophrenia. Which of the following findings should the nurse identify as negative symptoms? A. Hallucinations B. Inability to experience pleasure C. Disorganized speech D. Unusual behavior

Inability to experience pleasure *The inability to experience pleasure is a negative symptom of schizophrenia. Negative symptoms of schizophrenia are more difficult to detect. Other negative symptoms can include a lack of motivation, a blunt affect, a lack of interest, and a reduction speech

A nurse is reinforcing teaching with a client who has bipolar disorder and a new prescription for lithium. Which of the following directions should the nurse provide? A. Decrease sodium intake while taking lithium B. It may take 5 days before the medication is effective C. Take the medication on an empty stomach D. Increase the fluid intake to 2000 mL (67.6 oz) daily

Increase the fluid intake to 2000 mL (67.6 oz) daily *The client should consume 1500 to 3000 mL (50.7 to 101.4 oz) of fluid daily

The nurse is planning care for a patient with dementia. Which would be an appropriate intervention to include in this patient's care plan? A. Increase verbal and environmental cues. B. Speak loudly and slowly. C. Involve the patient in new activities. D. Restrain the patient for safety.

Increase verbal and environmental cues. *Increasing verbal and environmental cues (e.g., signs indicating bathroom and room locations) can help in orienting patients with dementia. There is no indication that the patient is hard of hearing. New activities would serve to confuse and perhaps agitate a patient with dementia.

A nurse is collecting data from a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate the administration of lorazepam? A. Decreased pulse rate B. Increased blood pressure C. Decreased urinary output D. Increased nausea

Increased blood pressure *Lorazepam is a benzodiazepine that is administered to a client who is experiencing alcohol withdrawal for stabilizing vital signs, preventing seizures, and treating delirium tremens. The nurse should anticipate the provider to prescribe lorazepam for increasing blood pressure

The nurse is caring for a patient with who is having difficulty with short-term memory. Which are other signs and symptoms of beginning Alzheimer disease? A. Increased forgetfulness, difficulty learning new things, inability to concentrate B. Unable to speak or ambulate and profound memory loss C. Social withdrawal and decreased ability to perform usual activities of daily living D. Outbursts of anger, hostility, paranoia, and wandering

Increased forgetfulness, difficulty learning new things, inability to concentrate

A nurse is collecting data from a client who has cocaine intoxication. Which of the following findings should the nurse expect? A. Low blood pressure B. Increased mental alertness C. Flat affect D. Decreased body temperature

Increased mental alertness *The nurse should expect a client who has cocaine intoxication to have increase mental alertness due to the substances stimulant properties

The nurse is caring for a suicidal patient who has been treated effectively with antidepressant therapy. The patient verbalizes that he feels better. The nurse is alert that the patient is most at risk for which potential complication? A. Increased risk for self-harm B. Increased emotional fragility C. Increased potential for weight gain D. Increased activity intolerance

Increased risk for self-harm *The risk of suicide is greater now that the patient has increased energy to plan and complete the suicide. Effective antidepressant therapy should not cause an increase in emotional fragility, weight gain, or activity intolerance

The nurse encourages the recovering alcoholic to participate in group therapy. Which benefit is most important for the nurse to mention? A. Development of improved social skills B. Progression toward sobriety C. Provision of a sense of belonging D. Increasing self-discipline

Increasing self-discipline *The learning of the skill of self-discipline is the long-lasting benefit from group therapy. The other options are also benefits, but the major one is self-discipline, a skill a drug abuser must acquire for successfuly rehabilitation

A nurse is assisting with the admission of a client who has tetraplegia. The nurse notes multiple bruises on the client and suspects abuse. Which of the following actions should the nurse take? A. Interview the client with the caregiver present B. Inform the provider that the caregiver is to blame for the abuse C. Begin the interview with simple close-ended questions D. Inform the client that nurses are required to notify protective services

Inform the client that nurses are required to notify protective services *The nurse should inform the client that nurses are required to report indications of abuse to protective services. An investigation will be performed to ensure the client's safety

A nurse is collecting data from a newly admitted client. To establish trust, which of the following actions should the nurse perform during the orientation phase of the nurse-client relationship? A. Inform the client that the admission is confidential B. Introduce the client to other clients in the dayroom C. Assist the client with facilitating behavioral change D. Determine coping strategies that the client has used in the past

Inform the client that the admission is confidential *According to evidence-based practice, the nurse should inform the client about confidentiality during the orientation phase of the nurse-client relationship. This action helps establish trust between the nurse and the client

A nurse is caring for a client who was admitted to the mental health unit for substance use disorder. The client states, "I am a nurse on the medical-surgical floor, and I don't want my coworkers to know I have been diverting drugs." Which of the following actions should the nurse take? A. Advise the client that her supervisor will be transferring her to another unit following treatment B. Inform the client that the information will be shared with the treatment team C. Explain to the client that there is a legal obligation to inform coworkers of her actions D. Tell the client her coworkers' opinion should not matter

Inform the client that the information will be shared with the treatment team *It is the nurse's legal duty to maintain the client's confidentiality. Only members of the client's treatment team should receive information about her medical history and care

A nurse is caring for a client who is receiving care at an inpatient alcohol treatment facility. Which of the following actions should the nurse identify as an example of an intentional tort? A. Administering an incorrect dose of benzodiazepine B. Informing the client's family member of the admission without the client's knowledge C. Informing the client that an injection will be administered if the client remains agitated D. Failing to recognize suicide risks, which results in the client's death

Informing the client that an injection will be administered if the client remains agitated *This is an example of assault. Assault is an intentional tort that is characterized by a threat toward a client that makes the client fearful of harm or unwanted touching

A patient taking an SSRI suddenly develops a rapid pulse, fluctuating blood pressure, fever, loss of muscle coordination, and mental status changes. You prepare for which intervention? A. Infuse IV fluids and administer an antipyretic B. Obtain an electrocardiogram and start oxygen through a nasal cannula C. Administer an antidote and encourage oral fluids D. Monitor the patient closely and continue the medication

Infuse IV fluids and administer an antipyretic *The patient is manifesting symptoms of serotonin syndrome. This is a potentially life-threatening condition that could start 30 minutes to 48 hours after taking the medication. Treatment includes stopping medication, administering IV fluids, and decreasing temperature. (2) The health care provider may order an electrocardiogram (ECG) to rule out other problems and giving oxygen for change of mental status is acceptable if pulmonary problems are suspected or oxygenation as measured by pulse oximetry is decreased. (3) There is no single antidote for this condition, and oral fluids are inappropriate for patients who are unstable. (4) Close monitoring is necessary, but the medication should be discontinued.

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are stating, "kill your doctor." Which of the following actions should the nurse take first? A. Encourage the client to participate in group therapy on the unit B. Initiate one-to-one observation of the client C. Focus the client on reality D. Notify the provider of the client's statement

Initiate one-to-one observation of the client *A client who is experiencing a command hallucination is at risk for injury to self or others. Safety is the priority, and initiating one-to-one observation is the first action the nurse should take *Encourage the client to participate in group therapy to assist with reality testing and to increase coping skills. However, there is another action to take first *Attempt to focus the client on reality. However, there is another action to take first *Notify the provider of the client's hallucination. However, there is another action to take first

A nurse is caring for a newly admitted client who is receiving treatment for alcohol use disorder. The client tells the nurse, "I have not had anything to drink for 6 hours." Which of the following findings should the nurse expect during alcohol withdrawal? A. Low body temperature B. Insomnia C. Muscle flaccidity D. Bradycardia

Insomnia *The nurse should expect the client who is experiencing alcohol withdrawal to have insomnia and restlessness

A nurse is reinforcing teaching with a client who has a new prescription for bupropion. The nurse should instruct the client to report which of the following findings as an adverse effect of bupropion? A. Hypotension B. Blurred vision C. Tinnitus D. Insomnia

Insomnia *The nurse should instruct the client to report insomnia, which is an adverse effect of bupropion. Other adverse effects can include anxiety, delusions, hypertension, dry mouth, nausea, weight loss or gain, and photosensitivity

Which symptoms are most characteristic of depression? A. Lack of interest, loss of libido, and a flight of ideas B. Insomnia, poor hygiene, and grandiose ideas C. Overeating, hyperactivity, and rapid speech D. Insomnia, anorexia, and lack of energy

Insomnia, anorexia, and lack of energy

A home health nurse is reinforcing teaching for the family who has moderate Alzheimer's disease. The family plans to care for the client in their home. Which of the following recommendations should the nurse include in the teaching? A. Place nonskid throw rugs over smooth surface floors B. Install locks at the top of exterior doors C. Provide clothing that has zippers instead of buttons D. Encourage frequent naps during the day

Install locks at the top of exterior doors *This client is at an increased risk of wandering and getting lost. A safety intervention to decrease the risk of wandering is to install locks at the tops of exterior doors since a client who has moderate Alzheimer's disease loses the ability to reach and look upward

A nurse in an acute mental health facility is assisting with the plan of care for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse recommend? A. Encourage the client to focus on personal hygiene B. Limit the hours the client sleeps each day C. Instruct the client to practice thought-stopping D. Make negative statements about the client's behavior

Instruct the client to practice thought-stopping *The nurse should suggest thought-stopping as an intervention for this client who has OCD. By saying "stop" out loud, the client can learn to interrupt obsessive thought.

A nurse is assisting with the preparation of a community education seminar about family violence. When discussing types of violence, the nurse should recommend to include which of the following? A. Refusing to pay bills for a dependent, even when funds are available, is neglect B. Intentionally causing someone to fall is an example of physical violence C. Striking a sexual partner is an example of sexual violence D. Failure to provide a stimulating environment for normal development is emotional abuse

Intentionally causing someone to fall is an example of physical violence *Physical violence occurs when physical pain or harm is directed toward another individual *Refusing to pay bills for a dependent is economic abuse, rather than neglect *Striking a sexual partner or other individual is an example of physical, rather than sexual, violence. Sexual violence occurs when sexual contact takes place without consent *Failure to provide a stimulating environment for normal development in neglect, rather than emotional abuse

When communicating with a severely depressed patient, what is the most therapeutic approach? A. Be quiet while assisting with activities of daily living B. Interact and talk with the patient and engage him in activities C. Make an extra effort to be cheerful and positive D. Speak in simple, direct sentences when necessary

Interact and talk with the patient and engage him in activities

The nurse is caring for a patient admitted with a diagnosis of serotonin syndrome. Which type of medication will most likely be included in the plan of treatment? A. Antihypertensive medications B. Intravenous (IV) therapy C. Antianxiety medications D. Sedatives

Intravenous (IV) therapy *Serotonin syndrome is a potential life-threatening condition that could start 30 minutes to 48 h after taking the medication. Symptoms include change of mental status, increase in pulse and fluctuation in blood pressure, loss of musclar coordination, and hyperthermia. Treatment includes stopping medication, administering IV fluids, and decreasing temperature

A nurse is caring for a client who has bipolar disorder and is experiencing hypomania. During a conversation with other clients, she becomes agitated and begins speaking in a loud, angry voice. Which of the following actions should the nurse take? A. Invite the client to take a walk B. Reprimand the client for her rude behavior C. Point out inappropriate behaviors to the client D. Administer trazodone to the client

Invite the client to take a walk *The client's increasing agitation demonstrates a potential for violent behavior. To maintain a safe environment, the nurse should remove the client from the situation and disperse her anger by walking and talking with her

A nurse is assisting with planning an in-service session about involuntarily commitment to mental health facilities for a group of newly licensed nurses. Which of the following pieces of information should the nurse recommend including? A. The client can challenge hospitalization following emergency treatment B. Involuntarily commitment requires the hospitalization of the client C. A client who is competent but committed involuntarily is unable to make treatment decisions D. Court hearings should be held 7 days after emergency commitment

Involuntarily commitment requires the hospitalization of the client *A client can be court-ordered to undergo outpatient psychiatric treatment as well as inpatient treatment. Involuntary outpatient treatment is used most often for clients who have severe and chronic mental illness in order to limit the need for inpatient admissions for the client

A person in jail for public intoxication has been without alcohol for 12 h. Which finding indicates that the patient may be withdrawing from alcohol? A. Irritability B. Nausea and vomiting C. Hallucinations D. Seizures

Irritability *Marked irritability is the early signs (6 to 12 h after last drink) of alcohol withdrawal

A nurse is collecting data on a client who has paranoid personality disorder. Which of the following manifestations should the nurse expect? A. Demonstrates extroverted behavior to gain attention B. Is always on guard around other people C. Is rigid about following rules and procedures D. Has an exaggerated sense of self-importance

Is always on guard around other people *A client who has paranoid personality disorder is hypervigilant and is always on guard because of a perception that others are out to get them. Clients who have this disorder are often tense and irritable and avoid interacting with other people

The nurse is educating a patient with a new prescription for lithium carbonate. Which information is most important for the nurse to include in the teaching plan? A. It can take up to 2 weeks for Lithium to reach a therapeutic level in the body B. Lithium is often given in conjunction with loop diuretics C. Carefully restrict sodium intake to less than 1 g/day D. Take medication before breakfast for maximum effectiveness

It can take up to 2 weeks for Lithium to reach a therapeutic level in the body *Lithium may take 7 to 14 days to reach therapeutic level in the body. Diuretics should be avoided while on Lithium therapy. Patients should not restrict sodium intake since low sodium levels could cause Lithium toxicity. Medication should be taken with meals to decrease gastric distress

A nurse is reinforcing teaching about stress management with a client who is experiencing anxiety. Which of the following techniques should the nurse recommend to assist the client in identifying his stressors? A. Biofeedback B. Intellectualization C. Journaling D. Cognitive reframing

Journaling *Journaling is a technique that can be used to identify stressors. By recording feelings and responses to events, the client can find the source of everyday stressors and begin the process of stress reduction

The delusional patient has become agitated and angry. The patient reports that the cook put tacks in his cereal. He is pacing back and forth in the crowded dining room and cursing the cook. How should the nurse respond? A. Keep distance from the patient and ask, "Can we go to the dayroom and talk?" B. Touch the patient's arm and say, "Calm down, I'm sure we can straighten this out." C. Call experienced CNAs to restrain the patient. D. Stand calmly and say, "This behavior is unacceptable. Sit down and eat, Carl."

Keep distance from the patient and ask, "Can we go to the dayroom and talk?" *Allowing the angry patient space is important. Encourage the patient to find a quieter place. Acknowledge the anger and demonstrate willingness to help. The agitated patient should not be touch without permission. Restraints are a last resort and will increase the patient's anger and feelings of persecution

A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal psychosis. Which of the following medications should the nurse prepare to administer? A. Lorazepam B. Methadone C. Thiamine D. Haloperidol

Lorazepam *Alcohol withdrawal psychosis can begin within g8 to 10 hours following alcohol cessation and is a medical emergency because it can lead to unconsciousness, seizures, or delirium. The nurse should prepare to administer the benzodiazepine lorazepam, which can be given by mouth or intramuscularly

A nurse on an acute care unit is providing postoperative care to an older adult client who develops delirium. Which of the following actions should the nurse take? A. Withhold PRN anti-anxiety medication B. Provide the client with a stimulating activity prior to bedtime C. Keep the client's room well-lit at night D. Encourage the client to make decisions about her daily routine

Keep the client's room well-lit at night *The nurse should keep the client's room well-lit. Adequate lighting can help her remain oriented to place upon waking at night and will promote safety if she becomes ambulatory

Which alternative to restraints will you select for an older adult patient on a medical-surgical unit who is confused and trying to get out of bed? A. Raise four side rails of the bed B. Put the patient's mattress on the floor C. Keep the patient in a wheelchair close to the nurse's station D. Use hand mitts and a soft vest with Velcro fasteners

Keep the patient in a wheelchair close to the nurse's station *Putting the patient close to the nurses' station is the least restrictive option. (1, 4) Raising the side rails and using mitts are considered types of restraints. If the nurse opts to use either of these measures, documentation and a health care provider's order are required. (2) Putting the mattress on the floor is not commonly done in a hospital, but it might be considered in other settings, such as the patient's home or a long-term care facility.

A nurse in a mental health facility is assisting with the care of a client who has antisocial personality disorder. Which of the following behaviors should the nurse expect the client to exhibit? A. Lack of remorse B. Self-mutilation C. Delusional behavior D. Splitting

Lack of remorse *A client who has antisocial personality disorder lacks empathy for others and shows no remorse of guilt for callous behavior

A nurse is determining the total score for a client's Alcohol Use Disorders Identification Test (AUDIT) by assigning a score of 0 to 4 for each of the client's answers. For which of the following self-reported findings should the nurse assign the client a score of 4? A. The client's frequency of alcohol intake is typically 3 times per week B. The client misses work once a month because of his alcohol intake C. Alcohol intake does not cause the client to have feelings of guilt D. Last month, the provider suggested that the client reduce his alcohol intake

Last month, the provider suggested that the client reduce his alcohol intake *When determining a client's total score for the AUDIT self-reported version, the nurse should assign a score of 4 if the client indicates that a friend, relative, or health care provider recommended decreasing his alcohol consumption at least once during the last 12 months

The nurse is assisting the patient with middle-stage Alzheimer's disease (AD) with dressing. Which action is most appropriate? A. Select clothes and dress the patient B. Layout clothing and coach the patient to dress self C. Ask the patient what he wants to wear D. Open the closet and tell the patient to choose a shirt

Layout clothing and coach the patient to dress self *Coaching the patient to dress himself helps preserve dignity and function. Selecting clothes and dressing the patient does not allow the patient to actively particpate in any way. Asking the patient what he wants to wear and telling him to choose a short could increase confusion and indecision

The family of an elderly patient who experiences nighttime confusion reports that he has been wandering from his room into the backyard. Which intervention will best decrease this patient's nighttime confusion? A. Assigning a family member to sit with him until he falls asleep B. Allowing the patient to share a room with another family member C. Leaving a night-light on D. Administering a sedative at the hour of sleep

Leaving a night-light on *Keeping the environment well lit is a strategy for decreasing confusion. Leaving a night-light on will help the patient remain oriented to the environment. Sedative effects may actually increase the likelihood of confusion in an elderly patient. A sitter until the onset of sleep will not help in the event the patient gets up and wanders around.

Which patient resonse indicates that large doses of vitamin B1 for treatment of Wernicke encephalopathy are working? A. No seizure activity B. Less confusion and improvement of memory C. Decreased urge to drink alcohol D. No tremors, nausea, or vomiting

Less confusion and improvement of memory *Patients with Wernicke encephalopathy are likely to show confusion, memory loss, and ataxia; it is a reversible condition that responds to vitamin B1. (1, 4) Seizure activity, tremors, nausea, and vomiting are signs of alcohol withdrawal. (3) Naltrexone (ReVia) is an example of medication used to help block the craving for alcohol.

A nurse is reinforcing teaching with a client who has bipolar disorder and a new prescription for valproic acid. The nurse should explain that the provider will routinely prescribe which of the following tests while the client is taking valproic acid? A. Electrocardiogram B. Chest X-ray C. Thyroid function tests D. Liver function levels

Liver function levels *The nurse should inform the client of the need to monitor liver function levels regularly due to the risk of hepatotoxicity while taking valproic acid. It is is recommended to obtain baseline levels and then repeat testing every 2 months during the first 6 months of therapy.

A home health nurse is collecting data from a client who has advanced dementia and whose caretake recently passed away. The client is not violent or suicidal. For which of the following treatment settings should the nurse recommend a referral for this client? A. Partial hospitalization B. Adult daycare facility C. Inpatient geropsychiatric unit D. Long-term nursing care center

Long-term nursing care center *A long term care nursing center provides intermediate or custodial care for clients who have acute or chronic illnesses. A client who has advanced dementia is a candidate for a skilled nursing facility because the client needs 24 hour nursing care and support

A nurse is assisting with the care of a client who is experiencing acute alcohol withdrawal. Which of the following medication should the nurse prepare to administer? A. Carbamazepine B. Clonidine C. Propranolol D. Lorazepam

Lorazepam *The nurse should expect to administer lorazepam, a benzodiazepine, as the first treatment for acute alcohol withdrawal. Along with decreasing symptoms of acute alcohol withdrawal, these medications can also maintain vital signs and prevent seizures and delirium tremens

The nurse is caring for a patient who has a heightened risk for seizures during his alcohol detoxification. Which medication may be included in the patient's care? A. Magnesium sulfate B. Chlordiazepoxide (Valium) C. Promethazine (Phenergan) D. Dicyclomine (Bentyl)

Magnesium sulfate *The person undergoing alcohol withdrawal is at risk for the development of seizures. Magnesium sulfate may be prescribed to prevent their onset. Chlordiazepxide may be administered to reduce anxiety. Promethazine (Phenegan) and dicyclomine (Bentyl) may be used to reduce symptoms such as naisea and vomiting

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take? A. Assign the client several tasks at the same time B. Maintain a low-stimulation environment C. Advise family to visit frequently as a group D. Encourage the client to make choices regarding care

Maintain a low-stimulation environment *To minimize confusion and anxiety, the nurse should maintain a low-stimulation environment who has demenita

A nurse is collecting data from an older adult client about possible abuse by her caregiver. Which of the following techniques should the nurse use? A. Avoid directly asking the client if she has been abused B. Use a confrontational speech C. Maintain a nonjudgmental tone D. Avoid being in the room alone with the client

Maintain a nonjudgmental tone *The nurse should use a nonjudgmental tone to promote trust and communication

A nurse is preparing to interview a client who has generalized anxiety disorder. Which of the following actions should the nurse take? A. Set the pace of the interview B. Place the chairs across from each other C. Position the chairs 1.2 m (4 ft) apart D. Maintain an open posture during the interview

Maintain an open posture during the interview *The nurse should be mindful of nonverbal cues such as eye contact, facial expressions, and posture. Maintaining an open posture conveys openness to what the client is saying, while a closed posture with arms crossed can make the client feel defensive

A nurse is contributing to the plan of care for a client who has borderline personality disorder and self-mutilates. Which of the following treatment approaches should the nurse recommend? A. Restrict participation in group therapy sessions B. Establish consequences for self-mutilation C. Maintain close observation of the client D. Provide an unstructured environment

Maintain close observation of the client *Clients who have borderline personality disorder are at risk of self-harm during times of increased anxiety. Maintaining close observation reduces the client's risk of injury

A nurse is contributing to the plan of care for a newly admitted client who has bipolar disorder and is experiencing acute mania. Which of the following client goals should the nurse identify as the priority? A. Practicing problem-solving skills B. Understanding the medication regimen C. Identifying indications of relapse D. Maintaining adequate hydration

Maintaining adequate hydration *The priority goal for this client is to prevent physical exhaustion, maintain health, and meet nutritional and rest needs during the acute phase of the client's manic episode.

A nurse is caring for a client who has generalized anxiety disorder (GAD). Which of the following goals should the nurse include in the discharge plan of care for this client? A. Use whistling or singing as a distraction to control hallucinations B. Make independent decisions about daily events C. Verbalize a realistic perception of personal appearance D. Decrease the use of ritualistic behavior

Make independent decisions about daily events *A client who has GAD demonstrates indecisiveness and has unrealistic and persistent anxiety most days of the week. This can cause the client to avoid situations that produce anxiety or to procrastinate necessary decision-making. The ability to make independent decisions about daily events is a goal the nurse should include in the discharge plan of care for the client

A nurse working in a retirement community is collecting data from an older adult client. Which of the following manifestations should the nurse identify as an expected age-related change? A. Making occasional errors when balancing a checkbook B. Confusion with time or place C. Poor judgment D. Changes in mood

Making occasional errors when balancing a checkbook *The nurse should identify that making occasional errors when balancing a checkbook is an expected age-related change in an older adult. Other manifestations can include needing occasional assistance with operating appliances, forgetting a name or an appointment and then remembering it later, difficulty finding the correct use of a word, and becoming tired after social activities

A nurse is assisting with a family therapy session. The younger child tells the nurse about plans to make the older sibling look bad, believing this will earn more freedom and privileges. The nurse should identify this dysfunctional behavior as which of the following? A. Placation B. Manipulation C. Blaming D. Distraction

Manipulation *Manipulation is the dysfunctional behavior of using dishonesty to support an individual agenda *Placation is the dysfunctional behavior of taking responsibility for problems to keel peace among family members *Blaming is the dysfunctional behavior of blaming others to shift focus away from the individual's own inadequacies *Distraction is the dysfunctional of inserting irrelevant information during attempts at problem solving

The nurse is aware that the older adult is at risk for drug-induced delirium. Which age-related change contributes to this risk? A. Slower bowel motility B. Reduced fluid intake C. Overall reduced metabolism D. Sedentary lifestyle

Overall reduced metabolism *Slower renal and liver clearance of drugs allows the drugs to accumulate in the system of the older adult

A nurse is conducting chart reviews of multiple clients at a mental health facility. Which of the following events should the nurse identify as an example of a maturational crisis? A. Rape B. Marriage C. Severe physical illness D. Job loss

Marriage *Marriage is an example of a maturational crisis, which is a naturally occurring event during the life span *Rape is an example of an adventitious crisis *Severe physical illess is an example of a situational crisis *Loss of a job is an example of a situational crisis

A nurse in a provider's office is assessing a client who is crying and states, "It's my child's first day of school." The nurse should recognize that the client is experiencing which of the following types of loss? A. Actual loss B. Maturational loss C. Perceived loss D. Situational loss

Maturational loss *A maturational loss is tied to a normal ,expected life change (e.g. children going to school or an adult moving out of state)

A nurse in a provider's office is collecting data for a client who has been taking donepezil for Alzheimer's disease. The data indicate that the client's disease is progressing and becoming more severe. Which of the following medications should the nurse expect the provider to prescribe? A. Megestrol B. Galantamine C. Memantine D. Haloperidol

Memantine *As Alzheimer's disease progresses and becomes more severe, memantine is added to the medication regimen. The medication is an n-methyl-D-aspartate antagonist, which can enhance cognition. It does not cure Alzheimer's disease

A nurse in a rehabilitation center is planning to reinforce medication teaching with a client who is being discharged following treatment for opioid use disorder. Which of the following medications should then nurse expect the provider to prescribe for the client? A. Diazepam B. Disulfiram C. Bupropion D. Methadone

Methadone *Methadone is used to decrease symptoms during the withdrawal phase of opioids. It is also used following withdrawal for maintenance therapy, as methadone decreases the euphoric effects of opiate drugs. Methadone can also lead to dependence, and the client will eventually need to be withdrawn from the medication

The nurse is caring for a patient addicted to heroin who is being treated for withdrawal symptoms. Which medication can the nurse anticipate will be prescribed to manage this condition? A. Naloxone hydrochloride B. Disulfiram C. Lorazepam D. Methadone

Methadone *Methadone maintenance programs are successful in helping patients who have a heroin addiction. Disulfiram is used as aversive therapy for alcoholism. Lorazepam is used for treatment of alcohol withdrawal. Naloxone hydrochloride is used to reverse narcotic and opiate overdose.

A patient with CNS stimulant use displays agitation and aggression. Which medication is the health care provider most likely to prescribe to address these symptoms? A. Methylphenidate (Ritalin) B. Lorazepam (Ativan) C. Ondansetron (Zofran) D. Naloxone (Narcan)

Methylphenidate (Ritalin)

A nurse is helping a client who has anxiety disorder select a nonpharmacological stress-reduction therapy for home use. Which of the following therapies engages the insular cortex of the brain to allow the client to focus on a single thought that is important to the client in the present moment? A. Guided imagery B. Progressive relaxation C. Cognitive reframing D. Mindfulness

Mindfulness *The practice of mindfulness engages the insular cortex as the person focuses on the sensations and surroundings of the present moment. The client learns to stop the mind from wandering to multiple thoughts and worries and to concentrate on a single thought or situation that is important at that time

A nurse working in a retirement community is collecting data from an adult client. Which of the following findings should cause the nurse to suspect the client is experiencing the early stages of Alzheimer's disease? A. Requiring help to record a television show B. Misplacing a family heirloom C. Feeling tired after a social gathering D. Completing tasks in a particular way

Misplacing a family heirloom *The nurse should identify that misplacing a valuable object such as a family heirloom occurs in the early stages of Alzheimer's disease. The nurse should continue to gather more information from the client and speak with the client's provider about the findings

A nurse is reinforcing preoperative teaching with a client who was informed of the need for emergency surgery. The client has a respiratory rate 30/min, and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify thay the client is experiencing which of the following levels of anxiety? A. Mild B. Moderate C. Severe D. Panic

Moderate *Moderate anxiety decreases problem solving and may hamper the client's ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious *In mild anxiety, the client's ability to understand information may actually increase *Severe anxiety causes restlessness, decreased perception, and an inability to take direction *During a panic attack, the person is completely distracted, unable to function, and can lose touch with reality

A 62-year-old woman is admitted to an assisted-living facility with symptoms of forgetfulness, anger outbursts, wandering, and paranoia. These would suggest which stage of AD? A. Mild B. Severe C. Moderate D. Moderate to severe

Moderate to severe *This patient's symptoms indicate her AD has progressed beyond the early stage. Later signs of disease progression include increasing confusion and inability to recognize self or others.

A nurse is caring for a client who was just admitted for treatment of anorexia nervosa. Which of the following actions should the nurse take? A. Discuss the nutritional value of foods during meal times B. Weight the client 3 mornings per week C. Allow the client to exercise for up to 1 hour per day D. Monitor the client for 1 hour following meals and snacks

Monitor the client for 1 hour following meals and snacks *The nurse should monitor the client after eating meals and snacks to prevent purging

A nurse is contributing to the plan of care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy B. Reinforce the use of the client appropriate coping mechanisms C. Check the client for comorbid health conditions D. Monitor the client for adverse effects of medications

Monitor the client for adverse effects of medications *Assisting with systematic desensitization therapy is a cognitive and behavioral, rather than a psychobiological intervention *Reinforcing the use of appropriate coping mechanisms is a counseling or health teaching *Checking for comorbid health conditions is health promotion and maintenance, rather than a psychobiological intervention

A nurse is assisting with the care of a client who has bipolar disorder. Which of teh following is the priority nursing action? A. Set consistent limits for expected client behavior B. Administer prescribed medications as scheduled C. Provide the client with step-by-step instructions during hygiene activities D. Monitor the client for escalating behavior

Monitor the client for escalating behavior *The greatest risk to this client is harming self or others due to the potential of a manic episode. Therefore, the priority actions the nurse should take is to monitor the client for escalating behavior *Set consistent limits for expected client behavior, administer prescribed medications as scheduled, and provide the client with step-by-step instructions during hygiene activities. However these do no address the client's priority need for safety and is therefore not the priority action

A nurse is caring for a client who has bipolar disorder and a new prescription for valproic acid. Which of the following actions should the nurse take? A. Monitor the client's liver function B. Avoid giving the medication with food or milk C. Counsel the client regarding medication dependency D. Limit intake of foods containing tyramine

Monitor the client's liver function *Valproic acid can cause severe hepatotoxicity and liver failure. The nurse should monitor the client's liver function at baseline and periodically thereafter. The nurse should also teach the client about the manifestations of liver failure

A nure is assisting with planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse expect to be assigned to perform first? A. Monitor the client's risk for self-harm B. Instill hope for positive outcomes C. Encourage the client to participate in group therapy sessions D. Assist the client to participate in treatment decisions

Monitor the client's risk for self-harm *The greatest risk to a client who has a body dysmorphic is self-harm or suicide. Therefore, the first action to take is to monitor the client's risk for self-harm to ensure that the client is provided with a safe environment *Instill hope for positive outcomes, without providing reassurance, as part of milieu therapy; however there is another action to take first *Encourage the client to participate in group therapy to assist the client in order to address social impairments that result from the disorder; however, there is another action to take first *Encourage the client to participate in treatment decisions as part of milieu therapy; however, there is another action to take first

A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action? A. Encourage the client to express feelings out loud B. Maintain eye contact with the client C. Move the client away from others D. Tell the client that the behavior is not acceptable

Move the client away from others *The behavior indicates that the client is at greatest risk for harming others. The priority action for the nurse is to move the client away from others.

A nurse in the emergency department is assessing a client who has generalized anxiety disorder. Which of the following actions should the nurse take first? A. Instruct the client to use guided imagery B. Move the client to a quiet area C. Assist the client in identifying his coping skills D. Allow the client time to express his feelings

Move the client to a quiet area *The greatest risk to this client is increased anxiety; therefore, the nurse should first move the client to a quiet area to decrease excessive stimuli

A nurse is caring for a child who has Tourette's disorder. Which of the following behaviors should the nurse expect? A. Multiple motor and vocal tics B. Areas of baldness on the scalp C. Insatiable hunger D. Exaggerated startle response

Multiple motor and vocal tics *The nurse should expect a child who has Tourette's disorder to display multiple motor and vocal tics. A tic is a sudden physical movement or vocalizations of sounds or words that are unrelated to the topic of conversation. Tics can change in frequency, severity, and location. Tourette's disorder is an inherited condition that causes clients to have multiple physical and 1 or more vocal tics

A patient reports taking chlorpromazine (Thorazine) for 4 months. Which symptom do you identify as a concern? A. Muscle rigidity B. Tongue protrusion C. Photophobia D. Dry eyes

Muscle rigidity *Muscle rigidity is a symptom of neuroleptic syndrome that is rare but potentially fatal. (2) Tongue protrusion is a sign of tardive dyskinesia, which may not be reversible even if medication is discontinued. (3, 4) Photophobia and dry eyes are anticholinergic symptoms that will respond to trihexyphenidyl (Artane) or benztropine (Cogentin).

A nurse is assisting with the care of a client who is experiencing opioid withdrawal. Which of the following manifestation should the nurse expect? A. Hyporeflexia B. Muscle spasms C. Constipation D. Decreased respiratory rate

Muscle spasms *Muscle spasms are a manifestation of opioid withdrawal

A nurse is assisting with planning care for a client who has completed detoxification from opioid abuse disorder. The nurse should plan to teach about which of the following medications? A. Methadone B. Naltrexone C. Buprenorphine D. Disulfiram

Naltrexone *The nurse should plan to educate the client on the medication naltrexone, an opioid antagonist that is used for the long-term maintenance of opioid use disorder. Naltrexone is the usual medication choice following detoxification from opioids

The nurse explains that an alternative to disulfiram (Antabuse) is the drug naltrexone (Vivitrol). Which information should the nurse include in the teaching plan? A. Naltrexone (Vivitrol) causes severe headaches if alcohol is consumed while using the drug B. Naltrexone (Vivitrol) can cause a dependence on the medication itself if taken improperly C. Naltrexone (Vivitrol) releases endorphin-like enzymes that mimic intoxification D. Naltrexone (Vivitrol) blocks craving and prevents relapse

Naltrexone (Vivitrol) blocks craving and prevents relapse *Naltrexone (Vivitrol) can be used to block the craving for alcohol and to prevent relapse in the recovery phase

A nurse is caring for a client in a mental health facility and overhears the client discussing plans to harm her father-in-law physically when she is discharged. Which of the following interventions should the nurse take? A. Ask the client to sign a contract agreeing not to harm others B. Notify the provider of the client's threat C. Keep the client's discussion confidential D. Place the client in individual observation

Notify the provider of the client's threat *It is the nurse's duty to notify the provider of the client's threat. It will then be the provider's responsibility to warn the the intended victim or the police of the client's threat

The nurse is caring for a patient with acquired immune deficiency syndrom (AIDS) dementia complex. Which factor places this patient at particular risk for injury? A. Manic behavior B. Numbness and muscle weakness C. Suicidal ideation D. Difficulty concentrating

Numbness and muscle weakness *Peripheral neuropathy results in numbness and muscle weakness that may contribute to falls and thermal skin injuries

The patient has bulimia nervosa. Which task would be appropriate to assign to the nursing assistant? A. Observe for marks on the knuckles during AM hygiene B. Listen outside the bathroom door for sounds of induced vomiting C. Check the patient's belonging for secret caches of snacks and good D. Escort the patient to group therapy or to occupational therapy

Observe for marks on the knuckles during AM hygiene

A nurse on an inpatient mental health unit is planning care for a client who was admitted following a suicide attempt. Which of the following actions should the nurse include in the plan? A. Keep the door of the client's room to open while the client is awake B. Ensure that the client's meal tray contains no knives C. Observe the client swallow medications D. Have a staff member observe the client once every 30 minutes

Observe the client swallow medications *The nurse should plan to observe when the client swallows medications to ensure that he does not save the medications to take all at once

The nurse observes a coworker who is always behind because he checks and rechecks the accuracy of his medication dosages. Even after being assured his dosages are correct, he checks them again. The nurse suspects her coworker suffers from which disorder? A. Perfectionism B. Phobic disorder C. Obsessive-compulsive disorder (OCD) D. General anxiety disorder

Obsessive-compulsive disorder (OCD) *When a person has an OCD, he experiences an obsession, recurrent, or intrusive thoughts that he cannot stop thinking about, and these thoughts create anxiety. Time spent in these thought and rituals can become overwhelming to the point of interfering with normal life

A nurse in a long-term care facility is caring for a client who has dementia and becomes increasingly agitated in the afternoon hours. Which of the following actions should the nurse take first? A. Place the client in a private room B. Apply soft wrist restraints to the client C. Administer haloperidol to the client D. Offer diversionary activities for the client

Offer diversionary activities for the client *When providing client care, the nurse should use the least restrictive intervention first; therefore, the nurse should offer activities to distract the client and redirect agitation and energy into behaviors that might calm the client

A patient with flight of ideas and easy distractibility cannot sit through mealtime. Which nursing intervention is appropriate? A. Give three high-calorie meals on a regular schedule B. Offer finger foods such as a meat and cheese sandwich C. Provide a pleasant, odor-free environment D. Encourage family meals and socialization while eating

Offer finger foods such as a meat and cheese sandwich *Offering foods that can be consumed "on the run" will increase the likelihood that the patient will eat something. (1) High-calorie foods are a good idea, but a regular schedule is going to be difficult for this patient at this point. (3) A pleasant, odor-free environment will not hurt, but it is more appropriate for patients who have anorexia related to nausea or for older adult patients. (4) Socialization for this patient is likely to cause distraction and result in decreased intake.

A nurse is reinforcing teaching with the caregiver of a client who has dementia. Which of the following instructions should the nurse include in the teaching? A. Offer the client a list of activities to choose from B. Offer finger foods to the client C. Discourage naps throughout the day D. Turn on the television when the client is in the room

Offer finger foods to the client *The caregiver should offer finger foods that the client can eat without sitting down. Clients who have dementia often like to wander and walk off nervous energy, which can decrease anxiety and calm the client.

A nurse is contributing to the plan of care for a group of clients. Which of the following interventions is the priority for the nurse to include? A. Offer high-calorie beverages to a client who is in the manic phase of bipolar disorder B. Practice relaxation techniques with a client who has anxiety disorder C. Assist a client who has depressive disorder with decision-making regarding group activities D. Reinforcing teaching to a client who has schizophrenia about a new prescription for clozapine

Offer high-calorie beverages to a client who is in the manic phase of bipolar disorder *Maslow's hierarchy of needs; therefore, the priority intervention is to offer the client high-calorie beverages. This intervention will help the client meet daily calorie requirements and prevent dehydration

A resident in a long-term care facility has been in a manic stage for 2 days. He has not slept and cannot focus long enough to eat a meal. How should the nurse best enhance the resident's nutrition? A. Insist he sit down and eat at the table B. Spoon-feed him at the table at regular mealtimes C. Offer him small glasses of high-protein drinks every hour D. Make up a game about who can finish a meal first

Offer him small glasses of high-protein drinks every hour *The patient displays an inability ti concentrate and a decreased need for sleep or nutrients. Offering a small amount of high-energy foods and drinks every hour will support nutrition until the manic behavior is under control. Because of the manic patient's abbreviated focus, eating an entire meal may not be possible. The nurse should not force the patient to sit and eat, demean him by spoon-feeding, or challenge him to process a new activity

A nurse is communicating with a client who was admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication? A. Offering advice B. Reflecting C. Listening attentively D. Giving information

Offering advice *Offering advice to a client is a barrier to therapeutic communication that should be avoided. Advice tends ti interfere with the client's ability to make personal decisions and choices *The technique of reflection directs the focus back to the client in order for the client to examine their feelings *The skill of active listening is an important therapeutic technique to help hear and understand the information and messages the client is trying to convey *Giving information informs the client of needed information to assist in the treatment planning process

A nurse is assisting with the planning of a staff education session about the administration of antidepressant medications to older adult clients. Which of the following pieces of information should the nurse recommend including? A. Older adult clients require a lower initial dose of antidepressant medication than adult clients B. Older adult client should not receive antidepressant medication C. Older adult clients achieve the therapeutic effects of antidepressant medications more quickly than adult clients D. Older adult clients have a decreased risk of adverse effects from antidepressant medication

Older adult clients require a lower initial dose of antidepressant medication than adult clients *Older adult clients should start at half of the adult dose for antidepressant medications. This is due to altered rates of absorption and the increased risk of adverse effects

A nurse is assisting with a staff education program on substance use in older adults. Which of the following information should the nurse to include in the presentation? A. Older adults require higher doses of a substance to achieve a desired effect B. Older adults commonly use rationalization to cope with a substance use disorder C. Older adults are at an increased risk for substance use following retirement D. Older adults develop substance use to mask manifestations of dementia

Older adults are at an increased risk for substance use following retirement *Requirement and other life change stressors increase the risk for substance use in older adults, especially if there is a prior history of substance use *Requiring higher doses of a substance to achieve a desired effect is a result of the length and severity of substance use rather than age *Denial, rather than rationalization, is a defense mechanism commonly used by substance users of all ages *Substance use in the older adult can result in manifestations of dementia

A nurse in a substance use disorder treatment facility is reviewing the medication records for a group of clients. The nurse should expect to administer methadone for a client who has a substance use disorder for which of the following substances? A. Amphetamines B. Opiates C. Barbiturates D. Hallucinogenics

Opiates *The administration of methadone is indicated for the treatment of opiate use disorder. Opiates include opium, morphine, codeine, methadone, and heroin. Methadone is given as a substitute to prevent cravings and severe manifestations of opiate withdrawal

A nurse is planning to work with a client to develop a set of goals. During which of the following phases of the therapeutic relationship should the nurse complete this task? A. Pre-orientation phase B. Orientation phase C. Working phase D. Termination phase

Orientation phase *The orientation phase is the period during which the nurse and the client become acquainted, establish rapport and boundaries, and develop goals and a plan of action to meet these goals. During this phase, the nurse also explains the nurse's role in maintaining confidentiality

A nurse is caring for a client who is taking olanzapine. For which of the following adverse effects should the nurse monitor? A. Orthostatic hypotension B. Tinnitus C. Hypoglycemia D. Tachycardia

Orthostatic hypotension *The nurse should monitor the client for orthostatic hypotension as an adverse effect of olanzapine. Other adverse effects of this medication can include bradycardia, agitation, dizziness, sedation, headaches, cough, dyspnea, abdominal pain, and photosensitivity

A patient admitted to the psychiatric unit states he is the "son of God" and insists he "will not be confined by mere mortals." Which is the most likely explanation for this behavior? A. Paranoia B. A stressful event C. Overwhelming anxiety D. A religious conversion

Paranoia *Delusions of grandeur are associated with paranoia. Conversion is generally expressed as sensory and motor deficits. Stressful events, religious conversion, and overwhelming anxiety do not manifest as delusions of grandeur.

A nurse is collecting data from a client who is experiencing post-traumatic stress disorder (PTSD) following a traumatic event. Which of the following medications should the nurse expect the provider to prescribe? A. Bupropion B. Phenelzine C. Mirtazapine D. Paroxetine

Paroxetine *The nurse should expect the provider to prescribe paroxetine, an SSRI that is considered the first-line treatment for PTSD.

A nurse is assessing a patient who has just returned to the unit after receiving ECT. Which assessment finding is of greatest concern? A. Patient complains of a headache B. Patient does not remember having ECT C. Patient displays a cardiac dysrhythmia D. Patient is disoriented to time

Patient displays a cardiac dysrhythmia

A patient has been diagnosed as having dementia. Which symptom should the LPN/LVN expect? A. Patient tends to have flight of ideas. B. Patient tends to be oriented to time, place, and person. C. Patient's speech tends to be slurred. D. Patient tends to confabulate.

Patient tends to confabulate. *Dementia is characterized by several cognitive deficits, memory in particular, and tends to be chronic. Confabulation is used to fill conversational gaps. Flight of ideas, slurred speech, and orientation to time, place, and person are not dementia symptoms.

A patient with a chronic substance use has a problem of denial or psychological dependence. Which outcome statement is most appropriate? A. Patient will stop denying dependence on substances B. Patient will list three negative effects that substances have on his life C. Patient will decrease substance use in 2 weeks D. Patient will talk to his wife about reasons for substance use

Patient will stop denying dependence on substances

A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the proper use of active listening? A. Offering self B. Using silence C. Paying attention to body language D. Reflecting feelings

Paying attention to body language *Active listening involves identifying verbal and nonverbal communication by the client, which includes paying attention to body language

The long-term care nurse notices that a resident with chronic dementia is uncharacteristically drowsy and lethargic. What is the appropriate nursing intervention? A. Allow the resident to go to sleep B. Include the resident in a social group for stimulation C. Perform a mental status examination and obtain vital signs D. Call the health care provider to report a change in mental status

Perform a mental status examination and obtain vital signs *The patient should be assessed for additional information about mental status, and vital signs should be obtained and then the health care provider called. (1) Allowing the resident to sleep could be dangerous if they are septic or having neurologic or cardiac problems or fluid and electrolyte imbalances that go undetected. (2) Stimulation with group participation is not appropriate, but the resident should be checked for arousability and response to normal stimuli. (4) The health care provider will need to be notified, but you do not have enough information to make the call until you further assess mental status.

The health care provider has ordered that the patient be restrained for 24 hours because he is a danger to himself or others. Which task is appropriate to assign to the nursing assistant? A. Selecting the type of restraint B. Checking the circulation in the area distal to the restraint C. Performing 1:1 observation D. Obtaining consent from the patient's family to use restraints

Performing 1:1 observation

A nurse is contributing to the plan of care for a client who has anorexia nervosa. The nurse should identify that which of the following actions is contraindicated for this client? A. Explaining that tube feeding are necessary if the client refuses oral intake B. Weighing the client each day prior to any oral intake C. Permitting the client to spend some quiet time alone after each meal D. Refraining from commenting on what the client is eating during mealtime

Permitting the client to spend some quiet time alone after each meal *The nurse should directly observe the client for at least an hour following meals. This intervention prevents the client from purging or discarding hidden food. Therefore, permitting the client to have alone time following meals is contraindicated for this client's plan of care

A nurse is collecting data from clients who are prescribed medications that can cause orthostatic hypotension. Which of the following medications requires a follow-up by the nurse? A. Phenelzine B. Escitalopram oxalate C. Galantamine D. Naltrexone

Phenelzine *Phenelzine is a monoamine oxidase inhibitor that is prescribed for depression and other mental health disorders. An adverse effect of phenelzine is orthostatic hypotension. The nurse should inform the client who is taking phenelzine that dizziness an lightheadedness are indications of hypotension. The nurse should also instruct the client to rise slowly from a side-lying or sitting position to minimize a drop in blood pressre

A nurse is contributing to the plan of care for a 10 year old child who has attention-deficit/hyperactivity disorder (ADHD). Which of the following types of the activities should the nurse include in the plan? A. Checkers B. Chess C. Ping-pong D. Reading

Ping-pong *The nurse should recommend including activities that require repetition and allow the child to get exercise, which can alleviate hyperactivity

A nurse working on an acute mental health unit is collecting data from a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actios is the nurse's priority? A. Place the client on one-to-one observation B. Assist the client to perform ADLs C. Encourage the client to participate in counseling D. Reinforce teaching to the client about medication adverse effects

Place the client on one-to-one observation *The greatest risk for a client who has MDD and comorbid anxiety is injury due to self-harm. The highest priority intervention is placing the client on one-to-one observation *The client who has MDD can require assistance with ADLs. However, this does not address the greatest risk to the client and is therefore not the priority intervention *Encourage the client who has MDD to participate in counseling. However, this does not address the greatest risk to the client and is therefore not the priority intervention *Reinforce teaching to the client who has MDD about medication adverse effects. However, this does not address the greatest risk to the client and is therefore not the priority intervention

A nurse is assisting with the care of a client who has a substance use disorder and was involuntarily admitted by court order for 90 days. When the nurse attempts to administer prescribed oral lorazepam to decrease the client's manifestations of withdrawal, the client aggressively refuses. Which of the following actions should the nurse take? A. Place the lorazepam on hold B. Request a prescription for IM lorazepam C. Request that another nurse attempt to administer the lorazepam D. Place the lorazepam in the client's food

Place the lorazepam on hold *Clients who are in a health care facility due to an involuntarily admission retain the right to refuse treatment, including prescribed medications. Therefore, the nurse should hold the medication, document the client's wishes in the medical record, and notify the provider of the refusal

The nurse hears in report that a patient has global amnesia. The nurse will allot extra time for which intervention? A. Talking about family members and their recent visits B. Reminiscing about family holidays and past events C. Reorienting to person, place, and time D. Placing signs and arrows to the bathroom and dining room

Placing signs and arrows to the bathroom and dining room

A nurse is collecting data from a client who has schizophrenia and is experiencing delusions. The nurse should identify that the client is experiencing which of the following types of symptoms? A. Positive B. Cognitive C. Negative D. Affective

Positive *The nurse should identify a client who has schizophrenia and is experiencing delusions is demonstrating a positive symptom. Positive symptoms are seen early in clients who have schizophrenia and are easier to detect that other types of symptoms. Other positive symptoms can include hallucinations, disorganized speech, and disorganized behavior

A nurse at a long term care facility notes that a client with dementia is having problems with orientation. Which of the following actions should the nurse take to improve the client's level of orientation? A. Encourage the client to make choices about meals and activities B. Use written signs to label specific rooms C. Post a large calendar on the bulletin board D. Place a wander alert electronic alarm bracelet on the client's wrist

Post a large calendar on the bulletin board *Posting a large calendar in a central location will assist the client with orientation

The nurse is caring for a patient who was admitted with fractures sustained during an MVC (Motor Vehicle Collision). The patient tearfully condfesses that she relives the accident in her dreams and is afrain to sleep. The nurse recognizes that this scenario is consistent with which disorder? A. Post-traumatic stress disorder (PTSD) B. Phobic disorder C. Obsessive-compulsive disorder (OCD) D. Panic level of anxiety disorder

Post-traumatic stress disorder (PTSD) *Individuals with PTSD have endured one or more extreme life-threatening events, and the remembrance of these events now produces feelings of intense horror, with recurrent symptoms of anxiety and nightmares or flashbacks

A nurse is reviewing laboratory reports of a client who has anorexia and is malnourished. Which of the following results should the nurse report to the provider immediately? A. Potassium 2.9 mEq/L B. Hemoglobin 10 g/dL C. Creatinine 0.5 mg/dL D. Sodium 136 mEq/L

Potassium 2.9 mEq/L *When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is potassium level of 2.9 mEq/L. The expected reference range for potassium is 3.5-5 mEq/L, with critical levels of less than 3 or greater that 6.1 mEq/L. A client who has a critical level of potassium is at great risk for cardiac dysrhythmias

A 25 year old patient is brought to the emergency department by the police. He is a poor historian but the police tell the nurse that they were called because he was wandering down the middle of the freeway. He appears confused, disheveled, and malnourished. Which problem statement on the care plan would be of highest priority for this patient? A. Altered self-care ability B. Wandering due to disorientation to time and place C. Potential for injury due to impaired decision making D. Altered nutrition

Potential for injury due to impaired decision making

A patient with command hallucinations is readmitted for an acute psychotic episode. What priority problem do you identify? A. Altered sensory perception B. Potential for violence C. Anxiety D. Altered coping ability

Potential for violence *The content of command hallucinations should be immediately assessed because the patient may be getting a command to harm self or others. (1, 3, 4) The other diagnoses are also relevant but less urgent.

A nurse is reviewing discipline techniques with the parents of an adolescent client who has oppositional defiant disorder. Which of the following techniques should the nurse recommend as an effective method of responding to the adolescent? A. Offering frequent physical touching B. Allowing self-regulation of boundaries C. Practicing planned ignoring D. Giving negative feedback

Practicing planned ignoring *Planned ignoring is an appropriate means of responding to clients who have oppositional defiant disorder. The nurse should reinforce the use of this technique with the parents as a response to the client's attention-seeking behaviors

A nurse is caring for a client with anorexia nervosa who has light skin. Which of the following findings should the nurse expect? A. Presence of lanugo B. Flushed skin tone C. Hyperactive bowel sounds D. Clubbing of the fingernails

Presence of lanugo *The nurse should expect a client who has anorexia nervosa to have lanugo (fine, neonatal-like hair growth) on the body as a result of malnutrition and starvation

A nurse is collecting data from a client who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect? A. Wide fluctuation in mood B. Report of a minimum of five clinical findings of depression C. Presence of manifestations for at least 2 years D. Inflated sense of self esteem

Presence of manifestations for at least 2 years *Manifestations of persistent depressive disorder last for at least 2 years in adults *Wide fluctuations in mood are associated with bipolar disorder *MDD contains a minimum of five clinical findings of depression *A decreased, rather than inflated, sense of self-esteem is associated with persistent depressive disorder

A nurse in a mental health unit is contributing to the plan of care for a client who is receiving treatment for self-inflicted injuries. Which of the following interventions is the priority for this client? A. Promoting and maintaining client safety B. Discussing reasons for the client's behavior C. Helping the client recognize feelings D. Reinforcing teaching with the client about alternative coping strategies

Promoting and maintaining client safety *The nurse should recognize that this client has self-inflicted injuries is at risk of further self-harm or suicide; therefore, the client's safety is the priority.

A nurse in an acute mental health facility is caring for a client who is experiencing an acute manic episode. Which of the following actions is the nurse's priority? A. Maintain the client's contact with her family B. Discourage the client's use of vulgar language C. Protect the client from impulsive behavior D. Redirect excessive energy to creative tasks

Protect the client from impulsive behavior *The nurse should protect this client who is manic from impulsive behavior that increases the client's risk of self-harm

A home health nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease. Which of the following instructions should the nurse provide? A. Have the client wear a medical alert necklace B. Place written signs on the bathroom and other doors in the house C. Prevent the client from taking naps during the day D. Provide a low stimulation environment

Provide a low stimulation environment *The nurse should reinforce with the caregiver that clients who suffer from impaired cognition require a low-stimulation environment. An environment of high-stimulation can lead to sensory overload, which can cause increased confusion and anxiety

What effect does the nurse desire to achieve by using clear, direct communication with patients with borderline personality disorder? A. Avoid generating an intense reaction from the patient B. Eliminate the possibility of manipulation C. Decrease the probability of the patient reacting emotionally D. Provide a role model for good communication

Provide a role model for good communication *Clear communication can model a communication style that allows a person to verbalize feelings and make thoughts and expectations known

A nurse is assisting with the plan of care for a client who has vegetative signs of depression. Which of the following actions should the nurse include in the plan? A. Limit snacking between meals B. Schedule regular naptimes during the day C. Weigh the client monthly D. Provide decaffeinated beverages

Provide decaffeinated beverages *A client who has vegetative signs of depression is at high risk for altered sleep. Because caffeinated beverages can interrupt restful sleep, the nurse should plan to offer the client decaffeinated beverages

A nurse is caring for a client who has dementia and paces during meals. Which of the following actions should the nurse take? A. Restrain the client during meals B. Offer a large meal to the client at bedtime C. Administer an antipsychotic medication D. Provide finger foods for the client

Provide finger foods for the client *The nurse should provide finger foods to encourage intake throughout the day and improve the client's nutritional status

A nurse is caring for a client with bipolar disorder who is experiencing a manic episode. Which of the following actions should the nurse take? A. Discourage the client from taking naps during the day B. Allow the client to choose which items of clothing to wear each day C. Encourage the client to participate in group therapy D. Provide high-calorie finger-foods frequently

Provide high-calorie finger-foods frequently *The nurse should offer the client frequent high-calorie snacks and meals during a manic episode to provide the calorie replacement needed due to excessive physical energy and activity. Providing finger-foods increases the client's intake when mania makes sitting down and concentrating on a meal

A nurse is discussing home care with the partner of a client who is in the late stage of Alzheimer's disease. The partner, who wil be the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following actions should the nurse take? A. Verify that a current power of attorney document is on file B. Instruct the client's partner to offer finger foods to increase oral intake C. Provide information on resources for respite care D. Schedule the client for placement of an enteral feeding tube

Provide information on resources for respite care *Providing information on resources for respite care is a correct action to provide the client's partner with a break from caregiving responsibilities *A power of attorney document does not address the client's care or the concerns of the caregiver *Clients in late-stage Alzheimer's disease are at risk for choking and are unable to eat without assistance. Offering finger foods is not a correct action *Placement of an enteral feeding tube is correct only with a prescription from the provider following a discussion that includes the provider, nurse, client's partner, and possibly social services and additional family members

A nurse is contributing to the plan of care for a client who has binge-eating disorder. Which of the following interventions should the nurse recommend? A. Weigh the client each day B. Provide the client with small, frequent meals C. Observe the client during meals for hiding food D. Offer liquid supplements during meals

Provide the client with small, frequent meals *The nurse should recommend providing small, frequent meals to the client. Long periods without food can cause a client who has a binge-eating disorder to relapse and overeat

A nurse in an acute mental health facility is participating in a group therapy session in which client enact situations to help them process past events. The nurse should identify that which of the following types of group therapy is being carried out? A. Psychoeducational group B. Psychodrama group C. Family therapy group D. Self-help group

Psychodrama group *In a psychodrama group, members actually take parts and act out a client's past experiences in the present time. This experience allows a client to process and gain insight into past experiences that present significant emotional issues

Needs substance to feel good A. Abuse B. Psychological dependence C. Addiction D. Tolerance E. Withdrawal

Psychological dependence

A 38-year-old patient has been admitted to the unit after ingesting a high dose of "bath salts." Which of the following conditions is the patient at the greatest risk for developing? A. Muscle cramping and abdominal pain B. Tachycardia and euphoria C. Diaphoresis and tachypnea D. Psychosis and suicidal ideation

Psychosis and suicidal ideation *"Bath salts" or "plant food," a powder that is inhaled, injected, ingested, or smoked to produce an effect close to that of cocaine or amphetamine. High doses bring a risk of violence, paranoid psychoses, and suicide. Tachycardia, euphoria, diaphoresis, tachypnea, muscle cramping, and abdominal pain are not associated with bath salts; rather, they are associated with opiate withdrawal. Amphetamine withdrawal causes bradycardia and depression.

A nurse is reinforcing teaching with a client who has a new disulfiram prescription for the management of alcohol dependence. Which of the following dietary choices should the nurse instruct the client to avoid? A. Peppermint candy B. Pure vanilla extract C. Salt D. Chocolate

Pure vanilla extract *The nurse should instruct the client to avoid alcohol-containing substances such as pure vanilla extract while taking disulfiram. The ingestion of alcohol while taking this medication causes a disulfiram-alcohol reaction, which is manifested by hyperventilation, dizziness, vomiting, and hypotension

A nurse is caring for a client who has a neurocognitive disorder and wanders at night. Which of the following actions should the nurse take to promote the client's safety? A. Put the client's mattress on the floor B. Keep the lights off in the client's room at night C. Limit snacks during the evening hours D. Turn off the client's radio or music player at night

Put the client's mattress on the floor *This action reduces the client's risk of injury from falling out of bed when confused or getting up to wander

The wife of an alcoholic tells the nurse, "My husband only drinks on the weekends to relax. He has a very stressful job." The nurse recognizes that the patient's wife is using which defense mechanism? A. Repression B. Denial C. Rationalization D. Identification

Rationalization *Rationalization is a justification for an unreasonanle act to make it appear reasonable. Rationalization is used by many families to allay their own anxiety about the substance abuse of a family member. Repression refers to unconsciously blocking an unwanted thought or memory from open expression. Denial is ignoring reality in spite of hard evidence. Denial is a mechanism frequently used by substance abusers. Identification refers to modeling behaviors after another individual

A nurse is caring for a client who is showing evidence of addiction to pain medication prescribed for rheumatoid arthritis. When questioned about the usage of the medication, the client states, "It is not an illegal drug." Which of the following defense mechanisms is the client using? A. Displacement B. Rationalization C. Projection D. Sublimation

Rationalization *Rationalization is the justification of unacceptable behavior by offering acceptable explanation. This is also known as making excuses

A long-term care facility resident with generalized anxiety disorder (GAD) enters the dining room and discovers that a visitor is sitting in her regular seat. The resident becomes agitated and insists that she cannot eat unless she sits in her chair. Which response is most appropriate? A. Instruct the visitor to move B. Reassure the resident that she can sit in her regular spot at supper C. Remind the resident that she will be hungry if she does not eat D. Insist that the resident eat

Reassure the resident that she can sit in her regular spot at supper *A calm approach and reassurance will help the anxious patient to mimic the nurse's behavior. Asking the visitor to move, telling the resident that she will go hungry, or insisting that the resident eat are not therapeutic and whll not help in reducing the patient's anxiety

A nurse is caring for a client with ADHD who has recently started taking lithium. For which of the following findings should the nurse monitor when evaluating the effectiveness of the medication? A. Increased attention span B. Decreased anxiety C. Reduced aggression D. Weight loss

Reduced aggression *Clients who have ADHD can experience a low tolerance for frustration, which can result in aggressive behaviors. Although psychosocial interventions should include developing coping mechanisms and cognitive behavior therapy, the client might require medication to manage aggressive behaviors. The nurse should monitor for reduced aggression when a client who has ADHD is taking a mood stabilizer such as lithium. Additional outcomes of mood-stabilizing medications include decreased impulsivity

A postoperative patient who also has alcohol use disorder was given chlordiazepoxide for increased blood pressure, increased pulse, tremors, nausea and vomiting, and diaphoresis. What is the rationale for use of this medication? A. Prevention of postoperative clot formation B. Reduction of symptoms of alcohol withdrawal C. Control of blood pressure D. Relief of postoperative nausea and vomiting

Reduction of symptoms of alcohol withdrawal *Chlordiazepoxide (Librium) is given to reduce the neurologic irritability associated with alcohol withdrawal. (1) Librium has nothing to do with clot formation. (3, 4) Librium should reduce symptoms, including elevated blood pressure and nausea and vomiting, that are part of the overall symptom set associated with withdrawal.

A nurse is speaking with parents who are at a clinic for a 2-week follow-up visit after the birth of their second child. They report that their 5-year-old daughter has started to wet the bed at night after being toilet trained for 2 years. The nurse should tell the parents that this is expected behavior and illustrates which of the following defense mechanisms? A. Compensation B. Repression C. Regression D. Suppression

Regression *Regression is reverting to a previous, more child-like behavior

A nurse is caring for a client who has generalized anxiety disorder. The client states, "I am so stressed about my work and finances. I can't think straight anymore." Which of the following actions should the nurse take first? A. Administer antianxiety medication B. Speak slowly and calmly C. Remain with the client D. Ask the client to talk about preceding events

Remain with the client *The greatest risk to this client is an injury from anxiety and distress, which can cause the client to lose control. Therefore, the nurse should remain with the client to convey acceptance and promote security

Which nursing action is appropriate immediately after a patient receives electroconvulsive therapy (ECT)? A. Remaining with the patient until she becomes oriented B. Administering oxygen at 6 L/min C. Restraining the patient for 24 h D. Discharging the patient home with instructions to rest for the following 24 h

Remaining with the patient until she becomes oriented *Patients are often disoriented after ECT; maintaining safety is a primary goal at this time. Oxygen is not standard treatment after ECT. Restraints are unnecessary and inappropriate. The patient should not be discharged until she is oriented and safety is ensured.

A nurse is reinforcing teaching with a school-age child who has conduct disorder and a new prescription for methylphenidate transdermal patches. Which of the following information should the nurse provide about the medication? A. Apply the patch once daily at bedtime B. Place the patch carefully in a trash can after removal C. Apply the transdermal patch to the anterior waist area D. Remove the patch each day after 9 hr

Remove the patch each day after 9 hr *The transdermal patch is applied once daily in the morning to a clean, dry area on the hip and is removed after 9 hr. For safety when discarding the transdermal preparation, the client should fold the patch and flush it down the toilet to prevent others from using it. The waist area should be avoided

A nurse is assisting with the plan of care for a client who is scheduled for electroconvulsive therapy (ECT). Which of the following interventions should the nurse add to the plan of care for this client? A. Maintain a clear liquid diet for 6 to hours prior to ECT B. Allow the client to sleep for 3 to 4 hours following ECT C. Administer IM epinephrine to the client prior to ECT D. Reorient the client to the environment after ECT

Reorient the client to the environment after ECT *Due to a transient period of confusion after the ECT, the nurse should plan to reorient the client

Shortly after receiving one dose of naloxone (Narcan) for an overdose of opiates, a patient experiences a change in level of consciousness and a decreased respiratory rate. What should the nurse do first? A. Inform the charge nurse B. Repeat the Narcan C. Notify the health care provider D. Update family members

Repeat the Narcan *Narcan has a short half-life, and opiate action may resume and cause respiratory depression. Narcan may be repeated, or thenurse can request a continuous intravenous infusion of the drug

The nurse is caring for a patient in the moderate Alzheimer stage. In planning care, the nurse should anticipate the need for which intervention? A. Repeat the date and time frequently B. Restrain the patient to protect from falls and wandering C. Vary routine and provide unstructured environment D. Allot extra time for grooming and toileting

Repeat the date and time frequently

A nurse is collecting data froma 4-year-old for indications of autism spectrum disorder. Which of the following findings should the nurse expect? A. Impulsive behavior B. Repetitive counting C. Destructiveness D. Somatic problems

Repetitive counting *Repetitive counting and strict routines are an indication of autism spectrum disorder *Impulsive behavior is an indication of ADHD rather than autism spectrum disorder *Destructiveness is an inidication of conduct disorder rather than autism spectrum disorder *Somatic problems are an indication of posttraumatic stress disorder rather than autism spectrum disorder

A nurse is reinforcing teaching with a client who has a new prescription for alprazolam for generalized anxiety disorder. Which of the following information should the nurse reinforce? A. Three to six weeks of treatment is required to achieve therapeutic benefit B. Combining alcohol with alprazolam will produce a paradoxical reponse C. Alprazolam has a lower risk for dependence than other antianxiety medications D. Report confusion as a potential indication of toxicity

Report confusion as a potential indication of toxicity *Confusion is a potential indication of alprazolam toxicity that the client should report to the provider *Buspirone, rather than alprazalom, requires 3-6 weeeks to achieve therapeutic benefit *Combining alcohol with alprazalam can produce CNS and respiratory depression rather than a paradoxical response *Alprazolam is preferably used for short-term treatment because of the increased risk of dependence

A nurse is collecting data from a client prior to the administration of lithium. The client began taking lithium 1 week ago for the treatment of mania. For which of the following findings should the nurse withhold the dose? A. Report of nausea with frequent episodes of emesis B. Weight gain of 1.8 kg (4 lb) since the start of treatment C. Fine tremors present in both hands D. Serum lithium level of 1.1 mEq/L

Report of nausea with frequent episodes of emesis *The nurse should identify that gastrointestinal upset with nausea and frequent emesis is an early indication of lithium toxicity; therefore, the nurse should withhold the prescribed dose and obtain a serum lithium level. The nurse should check the client for indications of dehydration, which further increases the risk of lithium toxicity

A nurse in a health clinic is treating a child who has bruises. The nurse suspects child abuse, but the provider disagrees and sends the client home. Which of the following actions should the nurse take? A. Request a social services consultation B. Contact the child's guardian to discuss the suspicion C. Report the provider's actions to the state medical board D. Report the suspected abuse to law enforcement

Report the suspected abuse to law enforcement *Nurses are legally mandated to report suspected child and vulnerable adult abuse. The nurse should report the suspected child abuse to the appropriate agency of the state in which she is practicing.

A nurse is caring for a client who has anxiety disorder. The client states that she forgot her partner's birthday after they had an argument. The nurse recognizes this action as which of the following defense mechanisms? A. Repression B. Splitting C. Conversion D. Projection

Repression *The nurse should identify that the client forgetting her partner's birthday following an argument is an example of repression. Repression is an unconscious exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness

A nurse at an acute care facility is assisting with the care of a client who is receiving IV antibiotic treatments for an infection. The client reported daily alcohol use at home. On the seconds day of admission, the client becomes agitated, hypertensive, and tachycardic. Which of the following actions should the nurse plan to take? A. Administer methadone when agitation increases B. Administer zolpidem before meals C. Request a prescription for a different antibiotic D. Request a prescription for chlordiazepoxide

Request a prescription for chlordiazepoxide *The nurse should recognize these findings as indications of withdrawal from alcohol and should intervene to decrease adverse manifestations. Chlordiazepoxide, an anxiolytic, is a benzodiazepine prescribed for alcohol withdrawal that reduces manifestation and can help prevent seizures and delirium tremens

A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take? A. Insist that the client stop yelling B. Request that other staff members remain close by C. Move as close to the client as possible D. Walk away from the client

Request that other staff members remain close by *Request that other staff members remain close by to assist if necessary *Do not make demands of the client by insiting that they stop yelling *Clients who are angry need a large personal space *Never walk away from a client who is angry. It is the nurse's responsibility to intervene as appropriate

A nurse in the emergency room is collecting data from a client who has heroin intoxication. Which of the following findings should the nurse expect? A. Seizure activity B. Respiratory depression C. Hypersensitivity to pain D. Increased mental alertness

Respiratory depression *Heroin is an opioid; therefore, the nurse should expect this client who has heroin intoxication to exhibit respiratory depression.

A nurse is assisting with monitoring a client who ingested an overdose of pentobarbital sodium. For which of the following adverse effects of toxicity should the nurse assess the client? A. Cerebrovascular accident B. Dysrhythmias C. Liver failure D. Respiratory depression

Respiratory depression *Pentobarbital is a barbiturate that is used for seizure disorders, induction of anesthesia, insomnia, and acute manic states and delirium. The most dangerous adverse effect of the medication is respiratory depression that can be fatal

A nurse in a mental health practitioner's office is communicating with a client. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? A. Offering general leads B. Summarizing C. Focusing D. Restating

Restating *Restating allows the nurse to repeat the main idea expressed *Offering general leads allows the nurse to take the direction of the discussion *Summarizing enables the nurse to bring together important points of discussion to enhance understanding *Focusing concentrates the attention on one single poing

A client states, "I haven't seen my child for 2 weeks." The nurse responds, "Your child has not visited you for 2 weeks?" Which of the following communication techniques is the nurse using? A. Accepting B. Making an observation C. Restating D. Voicing doubt

Restating *This is an example of the communication technique of restatement, which allows the nurse to verify what the client is saying and to provide an opportunity for the client to clarify any misunderstanding

A nurse is collecting data from a client who has generalized anxiety disorder (GAD). Which of the following findings should the nurse expect? A. Restlessness B. Choking sensations C. Paresthesias D. Excessive sleepiness

Restlessness *Clients who have GAD are irritable and restless. They tend to worry excessively about circumstances others might consider minor

A nurse on an inpatient rehabilitation unit is assessing a client who has a history of opioid use disorder and is experiencing withdrawal. Which of the following manifestations should the nurse expect? A. Hyperactivity B. Headache C. Rhinorrhea D. Tremulousness

Rhinorrhea *Rhinorrhea, lacrimation, pupillary dilation, yawning, and piloerection are classic manifestations of opioid withdrawal

A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following clinical manifestations should the nurse expect? A. Sedation B. Rhinorrhea C. Bradycardia D. Hypothermia

Rhinorrhea *The nurse should expect this client who is experiencing opioid withdrawal to have rhinorrhea and flu-like manifestations such as yawning, sneezing, and abdominal pain

A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat effect. The nurse should expect a prescription from the provider for which of the following medications? A. Chlorpromazine B. Thithixene C. Risperidone D. Haloperidol

Risperidone *Second-generation antipsychotics (risperidone) are effective in treating negative symptoms of schizophrenia (lack of grooming and flat effect) *First-generation antipsychotics (Chlorpromazine, Thithixene, and Haloperidol) are used mainly to control positive, rather than negative, symptoms of schizophrenia

A nurse is contributing to the plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse recommend including in the plan? A. Schedule specific times for the client to eat B. Compromise about foods the client is willing to eat C. Focus on the client's weight gain goal D. Weigh the child at the same time every week

Schedule specific times for the client to eat *The nurse should recommend scheduling specific meal times for the client. Mealtime can be stressful for clients who have anorexia nervosa, and this allows them time to prepare

The nurse is caring for a patient with moderate Alzheimer disease (AD) in a long-term care facility who "sundowns." The nurse understands that which action would be most beneficial for this patient? A. Scheduling social interaction in the morning B. Darkening the bedroom to encourage sleep C. Administering sedatives to enhance sleep initiation D. Scheduling an exercise program after supper

Scheduling social interaction in the morning *Sundowning occurs when a patient is completely oriented during the day but becomes disoriented and confused during the evening and night hours. Planning interactive activities when the residen is not confused is beneficial. Exercise programs at night would add to agitation and confusion. Sedatives also frequently cause confusion. Lights should be left on to assist with reorientation should the resident wake up at night

Which patient do you anticipate may have a dual diagnosis? The patient with A. Bipolar disorder and anxiety B. Alcohol use disorder and alcohol intoxication C. Schizophrenia and cannabis use disorder D. Major depressive disorder and PTSD

Schizophrenia and cannabis use disorder *Schizophrenia and cannabis use disorder are not related and are separate conditions. (1, 2, 4) The other conditions listed are related to each other and not standalone diagnoses.

A nurse is working with a client who exhibits extreme superstition, elaborate speech patterns, and eccentric behavior. The nurse should identify these features as which of the following personality disorders? A. Paranoid B. Histrionic C. Antisocial D. Schizotypal

Schizotypal *Findings of schizotypal personality disorder include a pattern of social impairments and cognitive alterations, including superstitious actions that are not congruent with the client's cultural norms, speech changes (e.g. an increase in use of metaphors), and other elaborate speech patterns

A nurse is contributing to the plan of care for a client who has suicidal ideation and is being transferred to the mental health unit. Which of the following interventions should the nurse recommend? A. Search the client and his belongings upon arrival B. Assign the client to a private room near the nurse's station C. Instruct assistive personnel to check on the client every 15 m in D. Keep the door to the client's room closed

Search the client and his belongings upon arrival *The nurse should plan to search the client and all of his belongings upon arrival to the unit. This search is conducted for the client's safety so that the nurse can identify and remove any objects that increase the client's risk of injury or suicide. Potentially harmfully objects include razors, shoelaces, hygiene products, and tweezers

A nurse is assisting with the admission of a client to an acute-care mental health facility following a suicide attempt. Which of the following actions should the nurse take first? A. Assess the client's level of self-esteem B. Document the client's mood and affect C. Attend an interdisciplinary team meeting D. Search the client's belongings

Search the client's belongings *The greatest risk to this client is self-injury from another suicide attempt; therefore, the nurse should first search the client's belongings to ensure there are no items that the client could use to harm herself.

The nurse is assigned to care for patients who are admitted for detoxification. Which drug represents the potentially highest risk situation during withdrawal? A. Cocaine B. Heroin C. Methadone D. Secobarbital

Secobarbital *A patient withdrawing from barbiturates requires gradual detoxification to prevent convulsions, delirium, tachycardia, and death. Although withdrawal from heroin, cocaine, or methadone is extremely uncomfortable and exhausting for the patient, it is not life threatening.

A nurse is preparing to administer a benzodiazepine to a client who has generalized anxiety disorder. The nurse should tell the client to expect which of the following adverse effects? A. Tinnitus B. Bradycardia C. Halitosis D. Sedation

Sedation *The client should expect sedation as an adverse effect of benzodiazepines because of the CNS depressant effects

A nurse is reinforcing teaching with a client who has panic disorder and a new prescription for clomipramine. Which of the following adverse effects should the nurse include in the teaching? A. Diarrhea B. Sedation C. Hypertension D. Urinary frequency

Sedation *The nurse should inform the client that adverse effects of clomipramine include sedation, orthostatic hypotension, and anticholinergic effects such as dry mouth, blurred vision, urinary retention, constipation, and tachycardia

A nurse is collecting dat from a school-aged child who has ADHD and has been taking desipramine. Which of the following adverse effects should the nurse expect the child's parent to report? A. Hyperactivity B. Depression C. Diarrhea D. Sedation

Sedation *The nurse should recognize that tryicyclic antidepressants can cause sedation, along with other anticholinergic effects. Therefore, the nurse should expect the parent to report that the child has been sedated

A nurse is reinforcing teaching with a client who has depression and is scheduled for transcranial magnetic stimulation (TMS). The nurse should reinforce with the client that TMS can cause which of the following adverse effects? A. Retrograde amnesia B. Seizures C. Confusion D. Suicidal ideation

Seizures *Although uncommon, seizures are a potential adverse effect of TMS

A nurse is caring for a client who has borderline personality disorder. Which of the following manifestations should the nurse expect? A. Self-mutilation B. Submission C. Exploitation of others D. Reclusive behavior

Self-mutilation *Clients who have borderline personality disorder exhibit impulsive behaviors such as suicidal plans and self-mutilation. Other impulsive behaviors include separation anxiety and splitting behaviors

The nurse explains that depression is thought to be the result of a deficit of which neurotransmitter? A. Norepinephrine B. Serotonin C. Acetylcholine D. Dopamine

Serotonin *Serotonin is a neurotransmitter of the central nervous center. It is important in sleep, pain perception, and emotional states. Lack of serotonin can lead to depression. Norepinephrine and acetylcholine are neurotransmitters of the autonomic nervous system. Norepinephrine plays and important role in the fight-or-flight reaction (constriction of the blood vessels, dilation of the pupils, increased heart rate, increased awareness, and vigilance). Acetylcholine causes decreased heart rate and force of contraction and plays a role in the sleep-wake cycle. Dopamine is located mostly in the brainstem. It is thought to play a rile in controlling complex movements, motivation, and cognition

A nurse is reviewing the medical record of a client who has a new prescription for tranylcypromine. The client still has a current prescription for sertraline. The nurse should notify the provider because taking these medications concurrently increases the client's risk of which of the following adverse effects? A. Increased intracranial pressure B. Serotonin syndrome C. Acute kidney injury D. Hypertensive crisis

Serotonin syndrome *Serotonin syndrome is a toxic effect that can occur from taking an MAOI such as tranylcypromine and an SSRI such as sertraline simultaneously. Manifestations include delirium, abdominal pain, muscle spasms, and irritability; these can worsen to cause cardiovascular shock and death. The nurse should notify the provider immediately of this potential interaction

A nurse in a provider's office is collecting data from a client who has obsessive-compulsive disorder (OCD). Which of the following prescriptions should the nurse expect the client to receive? A. Donepezil B. Venlafaxine C. Buproprion D. Sertraline

Sertraline *Sertraline is a selective serotonin reuptake inhibitor (SSRI) medication which is prescribed for anxiety disorders, including OCD

A patient displaying mania is investigating the unit and overseeing the activities of other patients; because of these behaviors, she is unable to finish her dinner. The nurse should institute which intervention to ensure proper nourishment for this patient? A. Allow her in the unit kitchen for extra food whenever she wishes. B. Encourage her appetite by ordering out for her favorite foods. C. Serve high-calorie foods she can carry with her. D. Serve her small, attractively arranged portions.

Serve high-calorie foods she can carry with her. *During periods of mania, the patient may be unable to sit long enough to complete a meal. Providing high-calorie finger foods will allow the patient to move around the unit while maintaining adequate nutrition. Attractively arranged portions, providing the patient's favorite foods, and allowing the patient to enter the unit kitchen whenever she likes would not help this patient attain proper nourishment.

The nursing student is assisting the nurse to apply restraints to a patient. Whch action by the student indicates that she understands the procedure? A. She checks the circulation and then applies the restraints B. She ties the knot so that it is not readily visible to the patient, family, or staff C. She states that she will check on the patient every 2-4 hours D. She documents the care that was given while the patient was in restraints

She documents the care that was given while the patient was in restraints

A nurse is establishing a relationship with a client who has major depressive disorder (MDD) and is withdrawn and quiet. Which of the following actions should the nurse take? A. Leave the client alone in the room B. Silently observe the client's behavior C. Provide the client with false reassurance D. Use descriptive words when addressing the client

Silently observe the client's behavior *The nurse should observe the behavior of a client who has MDD and is withdrawn. The client might not be ready to share feelings with the nurse, and questioning the client can increase the client's anxiety level

The CNA approaches the older adult in the long-term care facility and says, "Oh, look! Your pretty dress is icky with food spots! Let's change your clothes, sweetie." The nurse identifies that the CNA is using which type of communication? A. Instruction for personal hygiene B. Encouragement for self-care C. Simplistic "elderspeak" D. Reorientation techniques

Simplistic "elderspeak" *Elderspeak is a way of communicating with older adults, that is, infantile, over-simplistic, over-solicitous, and demeaning. It serves no therapeutic purpose

The nurse observes a withdrawn schizophrenic. The patient is sitting along and moving her lips as if she is talking, but there is no audible sound. The nurse speaks to the patient by name, but the patient does not seem to hear. What should the nurse do first? A. Hug the patient's shoulders, refer tothe patient by name, and ask if she's praying B. Document the patient's nonresponsiveness and continued detached behavior C. Sit down in the chair next to the patient, touch her arm, and speak softly D. Touch the patient's shoulder and then join another group of patients

Sit down in the chair next to the patient, touch her arm, and speak softly *Sitting with the patient and touching her presents the reality of the nurse's presence. Continued attention will make the patient feel safe. Feelings of safety are needed in the beginning of the nurse-patient relationship. Hugging the patient may invade the patient's personal space. The nurse's assessment will be documented but it is most appropriate to attempt an interaction with the patient

Which behavior is characteristic of a patient with schizoid personality disorder? A. Violation of the rights of others B. Excessive emotional outburst C. Attention-seeking behavior D. Social detachment

Social detachment *Patients with schizoid personality disorder exhibit behaviors such as withdrawal from social relationships and a restricted affect. Attention-seeking behaviors, excessive emotional outbursts, and the violation of the rights of others are not associated with schizoid personality disorders.

A nurse is caring for a client who has schizophrenia and is experiencing negative symptoms. Which of the following manifestations should the nurse expect? A. Hallucinations B. Impaired memory C. Dysphoria D. Social discomfort

Social discomfort *The absence of something that should be present is considered a negative symptom of schizophrenia. Social discomfort, the inability to enjoy activities, or a lack of goal-directed behavior are negative symptoms of schizophrenia

The nurse is caring for a patient receiving lithium for bipolar disorder. The nurse knows to monitor dietary intake of which electrolyte? A. Chloride B. Potassium C. Sodium D. Magnesium

Sodium *Sodium depletion or dehydration could cause lithium toxicity; therefore, monitor fluid intake and dietary sodium. Diuretics should be avoided. Lithium dosage is not related to chloride, potassium, or magnesium.

A nurse is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take? A. Address the client in a high pitched voice B. Speak to the client firmly and authoritatively C. Remove potentially harmful objects before leaving the client alone in the room D. Offer the client low-calorie or no-calorie fluids

Speak to the client firmly and authoritatively *Clients who are in a state of panic lose control of their emotions and behavior and feel terror. The nurse must protect the client from any harmful or impulsive behavior, and an authoritative approach can help accomplish this goal

A nurse is caring for a client who has major depressive disorder and is severely withdrawn. Which of the following techniques should the nurse use to facilitate communication with the client? A. Continue to talk if the client does not provide an immediate verbal response B. Use platitudes when talking with the client C. Ask the client direct questions D. Speak to the client using simple and concrete terminology

Speak to the client using simple and concrete terminology *The nurse should use simple and concrete terminology when communicating with this client. A client who is severely withdrawn has impaired comprehension and difficulty concentrating; therefore, this technique facilitates communication

A nurse on a mental health unit is caring for a client who has antisocial personality disorder and is becoming increasingly loud and belligerent. Which of the following approaches should the nurse use to manage this client's behavior? A. Confront the client for breaking the rules B. Stand close to the client to offer comfort and support C. Speak to the client with clear, calm, caring statements D. Escort the client to the nurse's station

Speak to the client with clear, calm, caring statements *To remain in control of the situation, the nurse should use clear, calm statements that are nonthreatening to the client. The nurse should also set limits for clients who exhibit potentially violent behavior

Which nursing action may aggravate the behavior of a patient who has paranoid tendencies? A. Providing written instructions regarding the patient's medication regimen B. Maintaining a structured environment C. Speaking in short, simple sentences D. Speaking in low tones to another patient in the area

Speaking in low tones to another patient in the area *Speaking so that this patient cannot hear may be interpreted negatively by the patient. Short and simple sentences, structured environments, and written instructions are appropriate for the patient with paranoia.

A nurse is reinforcing teaching about ethics with a newly licensed nurse. Which of the following actions should the nurse include as an example of beneficence? A. Taking a continuing-education course about recognizing risk factors of suicide B. Spending extra time reorienting a client who is experiencing command hallucinations C. Acknowledging and accepting a client's refusal of a psychotropic medication D. Describing the purpose, action, and side effects of a psychotropic medication

Spending extra time reorienting a client who is experiencing command hallucinations *The nurse should include this action as an example of beneficence, which is the duty to act to promote the good of others. Reorienting a client who is experiencing command hallucinations is the best interest of the client and can protect the client from harm

A nurse is caring for a client whp has borderline personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement is an example of which of the following defense mechanism? A. Regression B. Splitting C. Undoing D. Identification

Splitting *Splititng occurs when a person is unable to see both positive and negative qualities at the same time. The client who has borderline personality disorder tends to see a person as all bad one time and all good another time *Regression refers to resorting to an earlier way of functioning (having a temper tantrum) *Undoing is a behavior that is intended to undo or reverse unacceptable thoughts or acts (buying a gift for a spouse agfter having an extramarital affair) *In identification, the person imitates the behavior of someone admired or feared

A nurse is caring for a client who has borderline personality disorder (BPD). The client states, "You are the best nurse. All of the other nurses are mean." The nurse should identify that the client is demonstrating which of the following manifestations of BPD? A. Impulsivity B. Clinging C. Splitting D. Manipulation

Splitting *This client is demonstrating the defense mechanism of splitting, which is due to the client's inability to experience both positive and negative emotions at the same time. This inability results in the client's expression of feelings or emotions that are either all good or all bad

The health care provider writes an order for continuous observation for a patient admitted for an acute adverse response to a hallucinogenic drug. Which characteristic of hallucinogenic drugs makes close observation necessary? A. Rapid physical dependence B. States of altered perception C. Severe respiratory depression D. Both stimulant and depressant effects

States of altered perception *Hallucinogens produce altered perceptual states, making patient behavior unpredictable. Hallucinogenic drugs do not produce rapid physical dependence; they produce psychological dependence. Respiratory depression is an effect of narcotic use. Hallucinogens do not produce both stimulant and depressant effects.

A nurse is caring for a client who is experiencing a panic attack, Which of the following actions should the nurse take? A. Discuss new relaxation techniques B. Show the client how to change the behavior C. Distract the client with a television show D. Stay with the client and remain quiet

Stay with the client and remain quiet *During a panic attack, quietly remain with the client. This promotes safety and reassurance without additional stimuli *During a panic attack the client is unable to concentrate on learning new information. *During a panic attack, avoid further stimuli that can increase the client's level of anxiety

A nurse on a mental health unit is planning care for a client who has anorexia nervosa with purging behaviors. Which of the following interventions should the nurse include in the plan? A. Set the client's weight gain at 2.3 kg (5 lb) per week B. Allow the client to establish his own mealtimes C. Stay with the client for 1 hour following meals D. Have the client weigh himself daily

Stay with the client for 1 hour following meals *The nurse should plan to stay with and observe the client for 1 hour following each meal to discourage the client from hiding food or purging by self-induced vomiting

A patient is irritable, pacing, crying, and becoming increasingly agitated. Which is the appropriate nursing intervention? A. Discussing suicude openly B. Administering an ordered antidepressant medication C. Staying with the patient while making the surroundings less stimulating D. Offering small nourishing meals and finger foods to sustain nutrition

Staying with the patient while making the surroundings less stimulating *Making the area less stimulating and staying with the patient can lower anxiety. (1) The patient is not displaying signs of intending to commit suicide. (2) Antidepressant medication is not appropriate in this situation. (4) The patient is exhibiting signs of anxiety, not hyperactivity. Small nourishing meals and finger foods to sustain nutrition are more important for the patient with dementia who will not stay still.

The nurse is helping a patient get dressed to go to her dialysis treatement. The patient bursts into tears and says, "I can't go! I can't stand another day in that awful place. I will die if I have to go!" Which intervention is best? A. Stop the dressing process and calmly ask the patient to talk about her feelings B. Continue to dress the patient and reassure her that she will feel better after her treatment C. Stop the dressing process and remind the patient that missing a treatment can make her very sick D. Continue dressing the patient and remind her that she must stay on task in order to be on time

Stop the dressing process and calmly ask the patient to talk about her feelings *A calm and supportive attitude will help the patient identify feelings. The nurse should put the dressing process on hold so that the nurse can focus attention on a therapeutic response to the patient's concerns. The nurse shouls then ask an open-ended question to give the patient freedom to express her concerns. Making a threatening statement about consequences of missed treatements only exacerbates the patient's concern. Continuing to dress the patient while offering empty reassurance or changing the subject ignores the problem at hand

A nurse is collecting admission data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? A. Poor personal hygiene habits B. Strenuous exercise regimen C. Grandiose behaviors D. Intense fear of death

Strenuous exercise regimen *The nurse should expect a client who has anorexia nervosa to repost a strenuous exercise regimen. The client might participate in excessive physical activity due to the perceived need to burn calories and lose weight

A 31-year-old patient with a history of borderline personality disorder is admitted to the psychiatric unit after cutting both wrists with a kitchen knife. Which nursing approach would be most therapeutic for this patient? A. Open and flexible B. Nonintrusive and passive C. Structured and consistent D. Warm and nurturing

Structured and consistent *The nurse should be consistent and keep the environment structured when caring for a patient with borderline personality disorder. Open and flexible, warm and nurturing, and nonintrusive and passive do not provide boundaries for a patient with borderline personality disorder, and boundaries are crucial to the patient's management.

A nurse on an acute mental health unit forms a group to focus on self-management of medications. At each of the meetings, two of the members conspire together to exclude the rest of the group. This is an example of which of the following concepts? A. Triangulation B. Group process C. Subgroup D. Hidden agenda

Subgroup *A subgroup is a small number of people withing a larger group who function separately from that group *Triangulation is when a third party is drawn into a relationship withing two members whose relationship is unstable *Group process is the verbal and nonverbal communication that occurs within the group during group sessions *A hidden agenda is when some group members have a different goal than the states group goals. The hidden agenda is often disruptive to the effective functioning of the group

A nurse is assisting with a community presentation about Alzheimer's disease. The nurse should conclude that a member of the group requires further reinforcement of teaching when she identifies which of the following findings as a manifestation of Alzheimer's disease? A. Impaired judgment B. Sudden confusion C. Decreased attention span D. Short-term memory loss

Sudden confusion *The nurse should clarify that a client with Alzheimer's disease is expected to exhibit confusion that develops slowly over a period of months. Clients who have delirium exhibit sudden confusion

In planning care for the depressed patient, the nurse is aware that the risk for self-harm actually increases when the A. Patient is discharged and has to care for himself B. antidepressant medications begin to take effect C. family promises, but fails, to visit him in the hospital D. patient is first admitted and does not trust the staff

antidepressant medications begin to take effect

A home health nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver asks the nurse why the client becomes disoriented, confused, and often combative later in the day. For which of the following conditions should the nurse plan to gather more information? A. Electrolyte imbalance B. Hypothyroidism C. Sundowning D. Adverse effect of medication

Sundowning *Sundowning-an increase in confusion beginning in the afternoon and lasting into the night-is a common manifestation of Alzheimer's disease. The client can become confused, aggressive, agitated, and obsessive, leading to severe disorientation

A nurse is collecting data about the lethality of a client's plan for committing suicide. Which of the following plans should the nurse identify as a soft method of suicide? A. Jumping off a bridge B. Inhaling carbon monoxide C. Hanging with a rope D. Swallowing antidepressant pills

Swallowing antidepressant pills *The nurse should assess the lethality of a client's suicide plan and identify whether it is a hard or soft method. Ingesting antidepressants or other pills is considered a soft method because it has a lower risk of resulting in death than hard methods. Hard methods include jumping from a high place, carbon monoxide inhalation, hanging, and using a gun

A nurse is reinforcing dietary teaching with a client who has a new prescription for phenelzine, a monamine oxidase inhibitor (MAOI). The nurse should recognize that which of the following foods interacts with this medication? A. Swiss cheese B. Baked tilapia C. Banana D. Cottage cheese

Swiss cheese *Swiss cheese, and many other cheeses, are high in tyramine, which can interact with phenelzine. Phenelzine is an MAO that blocks neurotransmitters such as tyramine from being broken down. Therefore, ingestion of foods containing tyramine can increase the client's blood pressure and can cause a stroke. Foods that are high in tyramine should be avoided by a client who is taking an MAOI

An intoxicated patient is admitted to a treatment center for detoxification. The nurse understands that his withdrawal will be supported with which method? A. Psychotherapy support B. Large doses opioids to ensure sedation for 72 h C. Symptomatic relief until the substance clears his symptoms D. Titrated amounts of alcohol until severe withdrawal resolves

Symptomatic relief until the substance clears his symptoms *The alcoholic in withdrawal is supported with symptomatic relief for nausea and vomiting, cramps, and possible seizure

A patient is in the manic phase of bipolar disorder. He is talking very loudly and starting to argue with other patient. Which intervention is the most appropriate to try first? A. Instruct him to go sit down and watch television B. Take him for a walk down a quiet corridor C. Invite him to play cards or board games D. Advise him to lower his voice or lose privileges

Take him for a walk down a quiet corridor

The nurse is caring for a patient with moderate anxiety. Which activity should the nurse encourage to best manage the patient's anxiety? A. Taking a walk B. Learning a new game C. Watching an intense television show D. Reading a pamphlet about the negative effects of anxiety

Taking a walk *To best manage moderate level anxiety, the nurse should help provide outlets for tension. These activities include walking, crying, and working at simple, concrete tasks. Learning something new, watching an intense TV show, or reading information about the negative effects of anxiety are activities that may exacerbate anxiety rather than relieve it

A patient with a diagnosis of schizophrenia is experiencing auditory hallucinations and is admitted for evaluation and treatment. Which would be an appropriate activity for this patient? A. Taking a walk with the nurse B. Playing a game of solitaire C. Working on a large-piece puzzle alone D. Taking a nap

Taking a walk with the nurse *Strategies for helping patients to manage persistent auditory hallucinations include monitoring what triggers the hallucinations, talking with someone, listening to music, watching TV, saying "stop," using earplugs, doing deep breathing or relaxation exercises, and doing a favorite activity. Actively involving the patient will minimize active hallucinations. Solo activities such as solitaire, napping, and working on a puzzle alone provide ample opportunity for active hallucinations.

A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription for lithium. The nurse can safely administer which of the following medications while this client is taking lithium? A. Ibuprofen B. Haloperidol C. Valproic acid D. Hydrochlorothiazide

Valproic acid *Valproic acid and lithium are both indicated for the treatment of bipolar disorder. Therefore, the nurse can administer both of these medications to the client

A nurse is speaking with a client whose partner was killed unexpectedly. The client states, "I just don't know what to do now." Which of the following actions should the nurse take? A. Talk to the client about available community resources B. Distract the client by discussing events not related to the crisis C. Reassure the client that he will feel better soon D. Give the client advice about what to do during the next few days

Talk to the client about available community resources *Initial steps should be taken to make a client who is experiencing a crisis feel safe and less anxious. The priority for the nurse is to ensure the client is safe, which includes assessing any thoughts of self-harm. After promoting client safety, the nurse should let the client know what personal and community resources are available. The nurse should determine the client's perception of the crisis, availability of support, and ability to cope with the crisis.

A nurse in an emergency department is caring for a client who states, "I tripped over the dog again." The nurse notes the client has multiple lacerations and ecchymoses and sees in the client's medical record that she visited 2 months ago for similar injuries. Which of the following actions should the nurse take? A. Ask the client what she believes she did to deserve being physically abused B. Avoid documenting subjective verbatim statements from the client regarding injuries C. Talk to the client about making a safety plan D. Explain the cycle of violence to the client

Talk to the client about making a safety plan If the nurse concludes that physical abuse is occurring, it is important to support the client and take actions such as counseling the client about making a safety plan. The nurse should understand local laws regarding intimate partner violence and should report the incident as required

A nurse is caring for a client who has Alzheimer's disease and becomes agitated while refusing morning hygiene care. Which of the following actions should the nurse take? A. Talk to the client from 2-arm lengths away B. Obtain assistance to restrain the client for safety C. Firmly state to the client that morning care will be performed D. Call the provider to request a prescription for an antipsychotic medication

Talk to the client from 2-arm lengths away *The nurse should talk calmly and quietly to the client to decrease agitation. The nurse should remain 1 or 2 arm lengths away to provide a sense of personal space and maintain safety if she becomes aggressive

While sitting at the nurse's station, the nurse observes a patient using a tissue to pick up magazines and change the television channels. The nurse recognizes this as a new behavior for this patient. Which nursing action would be most important? A. Taking the tissues away from the patient B. Recognizing the behavior as attention-seeking C. Talking with the patient about the behavior D. Providing the patient with nonsterile gloves

Talking with the patient about the behavior *The nurse should question the patient regarding any changes in behavior to determine responses to treatment. It would not be therapeutic for the patient to have the tissues taken away, to be provided with nonsterile gloves, or to have the behavior recognized as attention-seeking.

A nurse is contributing to the plan of care for a client who has a physical dependence on alprazolam and must discontinue the medication. Which of the following actions should the nurse recommend? A. Taper the medication gradually over several weeks B. Encourage participation in stimulating physical activity C. Monitor the client for a return of anxiety for up to 72 hr following discontinuation of the medication D. Implement restraints and seclusion as needed

Taper the medication gradually over several weeks *The nurse should recommend tapering the dosage of alprazolam gradually over several weeks, possible months. This gradual reduction in dosage reduces the manifestations of withdrawal

The nurse is educating a patient with generalized anxiety disorder (GAD) who has a new prescription for buspirone (BuSpar). Which information is most important for the nurse to include in the teaching plan? A. Use this medication as needed to manage your anxiety B. Taper this medication before discontinuing C. Allow 3 weeks before expecting any relief of symptoms D. This medication poses a great risk of tolerance and dependence

Taper this medication before discontinuing *Patients should not stop taking BuSpar abruptly, but should taper this medication according to health care provider instructions. BuSpar is always given as a sheduled drug (never on an as-needed basis). The patient should allow 7 to 10 days for symptoms to subside. No evidence exists tht BuSpar causes tolerance of physical dependence

A nurse on an acute mental health unit is collecting data from a client who has obsessive-compulsive disorder (OCD). Which of the following behaviors should the nurse expect? A. Being intentionally dishonest B. Jumping rapidly between topics of conversation C. Tapping the 4 sides of a light switch D. Mimicking the movements of another person

Tapping the 4 sides of a light switch *Tapping the 4 sides of the light switch is an expected behavior for a client who has OCD. Clients with OCD have recurrent and persistent thoughts or urges that are suppressed by performing a compulsion or repetitive behavior

A nurse is assessing a client who has schizophrenia and takes haloperidol 3 times daily. The client has developed involuntary writhing movements of the tongue and constant lip smacking. These manifestations indicate which of the following adverse effects of haloperidol? A. Akathisia B. Acute dystonia C. Tardive dyskinesia D. Pseudoparkinsonism

Tardive dyskinesia *The nurse should identify that tardive dyskinesia can be manifested by involuntary movement of many body parts. Early findings include writhing movements of the tongue and smacking of the lips. The nurse should report these findings to the provider immediately because they might not be reversible and can progress to affect all extremities with rhythmic, uncontrollable writhing movements

A nurse is caring for a client who was voluntarily admitted to an inpatient mental health facility for treatment of major depressive disorder. After consenting to deep brain stimulation, the client tells the nurse he does not want to have the procedure. Which of the following actions should the nurse take? A. Explain that the provider is highly proficient in this therapy B. Tell the client that he has the right to refuse the procedure C. Explain that deep brain stimulation is a promising therapy for major depression D. Remind the client that agreeing to admission means the provider can proceed with the treatment

Tell the client that he has the right to refuse the procedure *Unless the client is a danger to himself or others, he has the right to refuse treatment, even after signing an informed consent form. The nurse should notify the provider to cancel the procedure

A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always threatening me." Which of the following actions should the nurse take? A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince them to admit to hiding the knife B. Keep the client's communication confidential, but watch the client and their roommate closely C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others D. Report the incident to the health care team, but do not inform the client of the intention to do so

Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others *The information presented by the client is a serious safety issue that the nurse must report to the health care team. Using ethical principle of veracity, the student tells the client truthfully what must be done regarding the issue

A nurse on a mental health unit is caring for a client who begins throwing objects at other clients. Which of the following actions is the priority nursing intervention? A. Attempt to restrain the client's arms B. Administer an anti-anxiety medication C. Place the client in seclusion D. Tell the client to stop the behavior

Tell the client to stop the behavior *When providing client care, the nurse should first use the least restrictive intervention; therefore, the nurse should talk to the client to encourage her to calm down and prevent harm to others

A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. Notify the nurse manager. B. Tell the nurse to stop discussing the behavior. C. Provide an in-service program about confidentiality. D. Complete an incident report.

Tell the nurse to stop discussing the behavior. *The greatest risk to this client is an invasion of privacy through the sharing of confidential information in a a public place. The first action to take is to tell the newly licensed nurse to stop discuinning the client's hallucinations in a public location *Notify the nurse manager if the clien't right to privacy is violated. However, there is another action to take first *Provide an in-service program for staff about confidentiality, However, there is another action to take first *Complete an incident report about the violation there is another action to take first

A nurse in an outpatient facility is assessing a 3-month-old infant who has lost weight and has injuries that indicate physical abuse. When preparing to interview the parent, which of the following actions should the nurse plan to take? A. Insist that the parent tell the nurse how the child was injured B. Tell the parent that a child protective agency must be notified C. Show disapproval to the parent regarding the infant's condition D. Call at least 2 other staff members to sit in the room during the interview

Tell the parent that a child protective agency must be notified *The nurse should tell the parent that a state protective agency must be notified of the infant's condition and explain the process to the parent

A nurse is reinforcing teaching about stress management techniques with a parent who has admitted to verbally abusing her children. Which of the following strategies is the nurse providing? A. Tertiary prevention B. Individual psychotherapy C. Family psychotherapy D. Primary prevention

Tertiary prevention The nurse is providing tertiary prevention methods by offering stress management techniques to the abuser after the abuse has occurred. Tertiary prevention methods facilitate the rehabilitative process for both victims of violence and those who perpetuate it

A nurse is discussing the benefits of group therapy with a client who has bipolar disorder. The nurse should identify which of the following as an advantage of this form of treatment? A. Decreased pressure from others to engage in unacceptable behaviors B. The chance to learn from the experiences of other individuals C. An outlet for increased energy during episodes of mania D. The opportunity to have increased participation time during therapy

The chance to learn from the experiences of other individuals *The nurse should identify the opportunity to learn and gain insight from other group members as an advantage of group therapy

A nurse on a pediatric mental health unit is receiving reports on 4 children. Which of the following reports should the nurse expect for a child who has an autism spectrum disorder? A. The child cannot sit still to be read to B. The child displays neck jerking tics C. The child has a ritualized behavior pattern D. The child bullies the other children on the unit

The child has a ritualized behavior pattern *Children who have autism spectrum disorder often display ritualized behavior patterns to the point of being inflexible with changes in routines. Minor changes to established routines can cause the child to become agitated

A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions by the client indicates transference behavior? A. The client asks the nurse if they can go out to dinner together B. The client accuses the nurse of being controlling just like an ex-partner C. The client reminds the nurse of a friend who died from substance toxicity D. The client becomes angry with the nurse and threatens to engage in self harm

The client accuses the nurse of being controlling just like an ex-partner *When a client views the nurse as having characteristics of another person who has been significant to their personal life and died from substance use (an ex-partner), this indicates trasnferance *(A) This indicates the need to discuss boundaries but does not indicate transferance *(C) This indicates countertransference rather than transferance *(D) This indicates the need for safety intervention but does not indicate transferance

A nurse is assisting with collecting an admission history for a client who has acute stress disorder (ASD). Which of the following client behaviors should the nurse expect? A. The client remembers many details about the traumatic incident B. The client expresses heightened elation about what is happening C. The client remembers first noticing manifestations of the disorder 6 weeks after the traumatic incident occurred D. The client expresses a sense of unreality about the traumatic incident

The client expresses a sense of unreality about the traumatic incident *The client who has ASD often expresses dissociative manifestations regarding the even, which includes a sense of unreality *The client who has ASD tends to be unable to remember details about the incident and can block the entire incident from memory *The client who has ASD reacts to what is happening with negative emotions (anger, guilt, depression, and anxiety). Elation is an emotion that can occur in clients who have mania *Manifestations of ASD occur immediately to a few days following the event

A nurse is reviewing the medical record of a client who has a new prescription for buproprion for depression. Which of the following findings is the priority for the nurse to report to the provider? A. The client has a family history of seasonal pattern depression B. The client currently smokes 1.5 packs of cigarettes per day C. The client had a motor vehicle crash last year and sustatined a head injury D. The client has a BMI of 25 and has gained 10 lb over the last year

The client had a motor vehicle crash last year and sustatined a head injury *The greatest risk to the client is development of seizures. Buproprion can lower the seizure threshold and should be avoided by clients who have a history of a head injury. This information is the highest priority to report to the provider

A nurse in a provider's office is reviewing the medical history of a client who asks about the use of varenicline for smoking cessation. Which of the following items in the client's medical history indicates a precaution for the use of varenicline? A. The client has type 1 diabetes mellitus B. The client has a history of depression C. The client has rheumatoid arthritis D. The client has a history of GERD

The client has a history of depression *The nurse should recognize that varenicline can cause mood changes and thoughts of suicide. Precautions should be taken when prescribing this medication to clients who have a history of psychiatric disease such as depression

A nurse on a mental health unit is caring for a client who is displaying signs of anger. Which of the following pieces of information about the client is the strongest indicator that the client might become aggressive? A. The client has marginal coping skills B. The client has a history of violence C. The client feels powerless after being hospitalized D. The client blames others for her problems

The client has a history of violence *The client's history of violence is the most important indicator that this client might become violent; therefore, this is the strongest indicator of potential aggressiveness.

A nurse is caring for a client who requests information about smoking cessation using nicotine gum. For which of the following reasons should the nurse recommend another over-the-counter smoking cessation product to the client? A. The client is overweight B. The client follows a vegan diet C. The client has dentures D. The client has insomnia

The client has dentures *The nurse should explain to the client that nicotine gum is difficult for clients who wear dentures to use and that using the gum can damage dental work. The nurse should recommend the nicotine patch or nicotine lozenges as an over-the counter alternative

A nurse in a provider's office is reviewing the medical record of a client who has major depressive disorder and a new prescription for phenelzine. Which of the following items in the client's history should the nurse report to the provider? A. The client uses a transcutaneous electrical nerve stimulation (TENS) unit for back pain B. The client has frequent headaches C. The client takes glucosamine sulfate for arthritis D. The client has a history of tinnitus

The client has frequent headaches *Severe or recurrent headaches is a contraindication for taking phenelzine and other MAOIs. The nurse should report this finding to the provider

A nurse in a provider's office is collecting data from a client who has been taking varenicline. Which of the following reports from the client indicate a therapeutic response to the medication? A. The client is taking fewer opioid pain relievers B. The client no longer has delirium tremens C. The client has reduced cravings for cigarettes D. The client is less hyperactive

The client has reduced cravings for cigarettes *Varenicline is prescribed for the treatment of tobacco use disorder. A therapeutic response to the medication is a decrease in cravings for nicotine. Other medications prescribed for this disorder include bupropion and clinidine

A nurse in a mental health clinic is caring for a client who has anxiety disorder related to post-traumatic stress disorder (PTSD). Which of the following actions by the client indicates a therapeutic response to treatment? A. The client spends most of the day in bed B. The client prefers to talk about things other than his anxiety C. The client seeks out environments with increased stimuli D. The client identifies situations that cause anxiousness

The client identifies situations that cause anxiousness *The client's ability to identify situations that lead to episodes of anxiety is an indication of a therapeutic response to treatment. If the client can foresee and prepare for these situations, the client will have a better chance of controlling emotions

A nurse is collecting data from a client who is taking buspirone to treat generalized anxiety disorder. Which of the following findings should the nurse identify as an adverse effect of this medication? A. Arthralgia B. Photophobia C. Xerostomia D. Bradycardia

Xerostomia *Buspirone can cause xerostomia, or dry mouth. Other adverse effects include headache, nausea, and insomnia

A nurse is collecting data from a client who has moderate cognitive decline due to stage 4 Alzheimer's disease. Which of the following findings should the nurse expect? A. The client requires assistance with eating B. The client frequently gets lost due to wandering C. The client has bladder incontinence D. The client is able to identify the names of family members

The client is able to identify the names of family members *The nurse should expect a client who has stage 4 Alzheimer's disease to recognize and identify family members. Clients who have Alzheimer's disease maintain this ability until stage 6

A nurse is collecting data from a client who is receiving disulfiram for alcohol aversion therapy. The client is experiencing palpitations and reports nausea, a headache, and extreme thirst. The nurse should identify that which of the following situations is occurring? A. The client is experiencing mild acetaldehyde syndrome B. The client is having delirium tremens C. The client is experiencing disulfiram toxicity D. The client is not having a therapeutic response to disulfiram

The client is experiencing mild acetaldehyde syndrome *The nurse should recognize that these manifestations are an indication of acetaldehyde syndrome, which occurs when alcohol consumption is combined with disulfiram use. The client's current manifestations represent the mild form of acetaldehyde symptoms that can occur by consuming as little as 7 mL (0.2 oz) of alcohol

A nurse is collecting data from a client who lost his mother a few months ago and is feeling depressed. Which of the following findings should cause the nurse to suspect the client has major depressive disorder? A. The client focuses on reuniting with his mother B. The client is unable to express pleasure C. The client reports feeling anger D. The client reports experiencing intense sadness

The client is unable to express pleasure *The client's inability to express pleasure is a manifestation of major depressive disorder. Other manifestations include decreased energy, depressed mood for most of the day, thoughts of death, being self-critical, and inappropriate guilt

A nurse in a provider's office is collecting data on a client who is taking paroxetine for the treatment of social anxiety. Which of the following information from the client should the nurse reports to the provider immediately? A. The client reports a change in appetite B. The client is experiencing insomnia C. The client reports being depressed D. The client is experiencing headaches

The client reports being depressed *A report of depression indicates that this client is at greatest risk for suicide. Therefore, this is the priority finding

A nurse is collecting data from a client who has ADHD and reports abruptly discontinuing his amphetamine treatment. Which of the following assessments indicates that the client is physically dependent on the amphetamines? A. The client exhibits paranoia B. The client reports having insomnia C. The client reports eating excessively D. The client has an increased heart rate

The client reports eating excessively *When amphetamine is taken at a therapeutic dose, it causes appetite suppression. Abrupt withdrawal of amphetamine can result in abstinence syndrome in a client who is physically dependent on the medication. Indications of physical dependence include excessive eating, exhaustion, depression, prolonged sleep, and a craving for more amphetamine

A nurse is collecting data from a client who has bipolar disorder and is in maniac state. Which of the followings is the highest priority? A. The client reports sleeping 2 to 3 hours per night B. The client speaks to the nurse in a demanding tone C. The client reports not attending group therapy D. The client reports not taking medication for the past 2 weeks

The client reports sleeping 2 to 3 hours per night *The greatest risk to this client is an injury from exhaustion due to lack of sleep; therefore, the priority is the client's report of decreasing sleep time

A nurse is caring for a client with schizophrenia who has been taking chlorpromazine for the pas 2 months. Which of the following findings demonstrates that the chlorpromazine has been effective? A. The client reports that hallucinations occur less frequently B. The client sleeps uninterrupted for 6 hours each night C. The client reports that she is the "most important person on the unit." D. The client demonstrates stereotyped behaviors

The client reports that hallucinations occur less frequently *The nurse should identify that a primary action of chlorpromazine, when used to treat schizophrenia, is to reduce hallucinations. Chlorpromazine, a first-generation conventional antipsychotic medication, is effective in decreasing delusions, hallucinations, and agitation. It can also treat manic behavior in clients who have bipolar disorder

A nurse in a provider's office is reviewing the results of a mental status exam for a client who has early manifestations of dementia. Which of the following pieces of information from the examination describes the client's cognitive status? A. The client has a flight of ideas B. The client shows a deficit in recent memory C. The client has a flat affect D. The client is well groomed

The client shows a deficit in recent memory *This report about the client's memory describes the client's cognitive status. Other areas include orientation, level of consciousness, attention, and judgment

A nurse is collecting data from a client who has bipolar disease. Which of the following actions is an indication the client is experiencing a manic stage? A. The client speaks rapidly with a sense of urgency B. The client touches everything within her reach C. The client states that she is unable to enjoy her favorite activities D. The client moves slowly and maintains a fixed gaze

The client speaks rapidly with a sense of urgency *The nurse should recognize that a client who is experiencing a manic episode often talks with pressured speech. This form of speech is rapid, frenetic, and often coherent and has a false sense of urgency

A nurse is reinforcing dietary teaching with a client who has a new prescription for a monoamine oxidase inhibitor (MAOI). Which of the following food selections by the client indicates an understanding of the teaching? A. Cheddar cheese B. Avocados C. Pepperoni D. Yogurt

Yogurt *Yogurt does not contain high amounts of tyramine and is allowed for clients who are taking an MAOI medication

A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization? A. The client describes a feeling of floating above the ground B. The client has suspicions of being targeted in order to be killed and robbed C. The client states that the furniture in the room seems to be small and far away D. The client cannot recall anything that happened during the past 2 weeks.

The client states that the furniture in the room seems to be small and far away *Stating that one's surroundings are far away or unreal in some way is an example of derealization *Feeling that one's body is floating above the ground is an example of depersonalization, in which the person seems to observe their own body from a distance *Having the idea of being targeted in order to be killed and robbed is an example of a paranoid delusion *Being unable to recall any events from the past 2 weeks is an example of amnesia

A nurse is observing a client who has histrionic personality disorder. Which of the following behaviors should the nurse expect? A. The client whispers in the provider's ear B. The client refuses to provide her telephone number C. The client has diminished facial expressions D. The client asks if she is doing the right thing 3 times during the appointment

The client whispers in the provider's ear *Acting provocatively and seductively is an expected behavior of an individual with histrionic personality disorder

A nurse is counseling a client following a recent death in the family. Which of the following situations should the nurse identify as a risk factor for maladaptive grieving? A. The death was a result of violence B. The client expresses anger over the loss C. This is the client's first experience of the loss of a family member D. The client demonstrates reorganization of behavior

The death was a result of violence *When death is a result of violence, is traumatic, or is unexpected, the loss can result in maladaptive grieving for those left behind. This type of grief is complicated by the survivors not having an opportunity to prepare for the death or to say goodbye

A nurse is admitting a client who has derealization disorder. Which of the following manifestations should the nurse expect? A. The inability to recall important personal information B. The feeling that the surroundings are unreal C. The inability to recall identity D. The presence of at least 2 distinct personalities

The feeling that the surroundings are unreal *The feeling that the surroundings are unreal or distant is a manifestation of derealization disorder. Clients who have this disorder might feel mechanical, dreamy, or detached from their body. Often, the manifestations are destressing and come and go. The disorder occurs as a response to acute stress

A nurse is caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication? A. The nurse discusses the client's weight loss during a health care team meeting B. The nurse examines their own personal feelings about clients who have anorexia nervosa C. The nurse asks the client about personal body image perception D. The nurse presents an educational session about anorexia nervosa to a large group of adolescents

The nurse asks the client about personal body image perception *The nurse's one-on-one communication with the client is an example of interpersonal communication *The nurses's discussion of client information with members of the health care team is an example of small-group communication *The nurse's self-assessment of feelings is an example of intrapersonal communication *The nurse's educational presentation to a large group of adolescents is an example of public communication

A depressed patient is threatening to harm himself. Which nursing action indicates an understanding of the appropriate care of the suicidal patient? A. The nurse asks the patient if he has a plan. B. The nurse calls the family and asks them to visit the patient. C. The nurse administers a sedative. D. The nurse places the patient in seclusion.

The nurse asks the patient if he has a plan. *When a patient is threatening suicide, is it crucial to ask if the patient has a specific plan to determine the patient's risk. Sedative administration, seclusion, and family visits are not the appropriate interventions for a patient threatening suicide.

A recently licensed nurse is orienting to the Alzheimer disease (AD) care unit. The nurse is caring for a patient who is transitioning from oral rivastigmine (Exelon) to the medication patch. Which action indicates an accurate understanding of the medication? A. The nurse instructs the patient to apply the patch 12 h after the last oral medication dosage B. The nurse instructs the patient to replace the patch every 36 h C. The nurse explains that the sites of application will need to be rotated D. The nurse instructs the patient to avoid placing the patch on the trunk region of the body

The nurse explains that the sites of application will need to be rotated *Rivastigmine (Exelon) is used to manage AD by elevating acetylcholine. The medication is available orally and transdermally. The patch should be applied 24 h after the last oral dosage is given. The sites for application of the drug patches should be rotated

The nurse is caring for a patient who has dementia and has been getting up out of bed at night. What action by the nurse is most therapeutic? A. The nurse raises all of the side rails B. The nurse reassigns the patient to a room closer to the nurse's station C. The nure obtains orders from the physician to apply restraints at night D. The nurse places the mattress on the floor

The nurse places the mattress on the floor *The patient poses a significant risk for falls and needs provisions to increase safety. Placing the mattress on the floor decreases the risk of injury from falling from a larger height. Moving the patient closer to the nurse's station does not offer protection or ensure that the patient will be seen or heard. The use of side rails can be considered a restraint and it can present an additional safety hazard. Restraints are to be the last option when caring for patients

A nurse is collecting data from a toddler who has a fractured arm. Which of the following findings should the nurse identify as a possible indication of physical abuse? A. The parent provides a history that is inconsistent with the child's injury B. The child is brought to the health care facility immediately following the injury C. The parent requests to remain present with the child throughout treatment of the injury D. The child clings to the parent when the nurse begins to examine the injury

The parent provides a history that is inconsistent with the child's injury *The nurse should suspect possible abuse when the child's injury conflicts with the history of the injury reported by the parent

Which action best aids in successful rehabilitation from substance abuse? A. The patient and family members collaborate to develop treatment goals B. The patient and family members accurately list signs of relapse C. The patient and family members commit to discarding all drugs and paraphernalia D. The patient and family members commit to a 12-step program

The patient and family members collaborate to develop treatment goals *Collaboration is basic for success of rehabilitation. The patient and family must be part of the decision-making process for the formulation of treatment goals. While it is important to be aware of signs of relapse and essential to discard any paraphernalia and a 12-step program could be helpful, it is most important for the patient and family members to be active participants in the treatment plan

In which situation should the nurse document that the patient with AD exhibitied agnosia? A. The patient attempts to comb her hair with a fork B. The patient struggles to express herself verbally C. The patient appears unable to understand written language D. The patient cannot feed herself, despite having adequate motor function

The patient attempts to comb her hair with a fork *Agnosia is the inability to recognize an object and use it as intended. Expressive aphasia is difficulty in expressing oneself. Alexia is the inability to recognize the written language. Apraxia is the inability to do an activity despite having the motor function to accomplish it

The patient with Alzheimer's disease (AD) has been on donepezil (Aricept) for several weeks. In which situation would the nurse suspect an overdose? A. The patient hungrily eats meals and often searches for snacks between meals B. The nurse assesses a radial pulse rate of 92 beats per minute C. The patient's blood pressure is elevated after periods of exertion D. The patient fails to grasp a glass tightly enough to prevent dropping it

The patient fails to grasp a glass tightly enough to prevent dropping it *Inability to grasp the glass indicates muscle weakness, a cardinal indicator of overdose of Aricept. Other overdose signs are hypotension, nausea, and vomitingm and bradycardia. Appetite changes are not consistent with the use of this medication

When receiving report, the nurse learns that a schizophrenia patient has been displaying waxy flexibility. Which behavior is consistent with this report? A. The patient sits and stares at the wall without speaking B. The patient arranges himself in several seated postures on the couch C. The patient marches stiffly up and down the center of the dayroom D. The patient holds his arm over with his fist clenched for an hour

The patient holds his arm over with his fist clenched for an hour *Waxy flexibility refers to maintaining a limb in one position for a long time. The catatonic patient will exhibit a stuporous demeanor. It is associated with rigidity and unusual posutring

The nurse has asked a catatonic patient, "Where is your hat?" Which response should cause the nurse to document episodes of echolalia? A. The patient excitedly says, "Hat, cat, rat, fat, scat, splat!" B. The patient tearfully says, "I had a hat when my mother drove her yellow car." C. The patient repeatedly says, "Your hat, your hat, your hat." D. The patient places his hands on his head and says, "Where is your hat?"

The patient places his hands on his head and says, "Where is your hat?" *Echolalia is the repetition of words spoken to the patient by another person

The nurse is caring for a schizophrenic patient who has been prescribed large doses of thioridazine. Which manifestaton may signal an overdose of the medication? A. The patient walks with a shuffling gait and drooling B. The patient is lethargic and takes frequent naps C. The patient exhibits disorganized thought processes D. The patient exhibits extreme excitability with periods of mania

The patient walks with a shuffling gait and drooling *Extrapyramidial side effects of pseudo-parkinonism with a shuffling gait, tremors, and excessive salivation are cardinal signs of overdose of neuroleptics

A nurse is collecting data from an adult client whose sister recently died in a motor vehicle crash. The nurse should identify that which of the following factors indicates an increased risk for a complicated grief reaction? A. The loss of a sibling B. The perception that the death was unavoidable C. The sudden occurrence of the death D. The presence of a social support network

The sudden occurrence of the death *A sudden, unanticipated death can complicate the mourning process and lead to a complicated grief reaction. Other factors include death from a lengthy illness, the loss of a child, or the perception that the death was preventable

An older adult resident in a long-term care facility expresses multiple minor complaints at the nurse's station and wanders about aimlessly in the hallway. The nurse examines the patient's chart. Which newly prescribed drug may explain his behavior? A. Tylenol B. Theophylline C. Bisacodyl D. Lisinopril

Theophylline *The drig theophylline may make patients feel anxious and restless. Tylenol, biscodyl, and lisinopril do not typically have this effect

A nurse is communicating with a newly admitted client. Which of the following rationales identifies the nurse's purpose for using therapeutic communication with the client? A. Therapeutic communication identifies and analyzes the client's problems B. Therapeutic communication builds a relationship that will allow expression of mutual concerns C. Therapeutic communication provides a foundation for the client's relationship with the provider D. Therapeutic communication ensures the client will remain cooperative with care in the facility

Therapeutic communication builds a relationship that will allow expression of mutual concerns *The purpose of therapeutic communication is to facilitate a relationship that will allow expression of mutual concerns in an effort to address the client's health issues

The patient is taking lorazepam (Ativan) for anxiety. The nurse advises him not to drink alcohol while taking this drug for which reason? A. There is an increase in blood pressure caused by frequent use B. There is an additive effect on the nervous system C. There is a decrease in therapeutic response caused by frequent use D. There is increased risk for insomnia and gastrointestinal distress

There is an additive effect on the nervous system

The nurse is caring for an elderly patient who is prescribed triazolam (Halcion) for insomnia. Benzodiazepines must be used cautiously in the elderly because A. They have a long half-life and are not excreted readily B. They are toxic to the aging endocrine system C. Tolerance causes use of increasing doses D. They may be used along with alcohol

They have a long half-life and are not excreted readily

The nurse is caring for a patient who is undergoing detoxification from alcohol. Which supplement can the nurse expect to be included in the prescribed medications? A. Potassium chloride B. Thiamine C. Roboflavin D. Folic acid

Thiamine *The treatment for the alcoholic undergoing detoxification includes the administration of large doses of thiamine (vitamin B1). Thiamine acts as a nerve insulator in the body and is absent in the diets of most chronic alcoholics

A nurse is reinforcing teaching with a client who wants to stop smoking by using nicotine gum. The nurse should inform the client that which of the following adverse effects can occur from using nicotine gum? A. Itching B. Throat irritation C. Hiccups D. Teary eyes

Throat irritation *The nurse should instruct the client that throat irritation is an adverse effect of chewing nicotine gum. Other adverse effects include mouth irritation, aching jaw muscles, and dyspepsia

A nurse is caring for a client who is taking carbamazepine. The nurse should monitor the client for which of the following adverse effects of carbamazepine? A. Thrombocytopenia B. Weight loss C. Polyuria D. Insomnia

Thrombocytopenia *The nurse should monitor the client for thrombocytopenia (an increased risk of bleeding). The nurse should monitor for bleeding of the gums, which can indicate thrombocytopenia, and notify the provider if this occurs.

A nurse in a mental health facility is meeting with a client who has a diagnosis of major depression. During the conversation, the client stops speaking, and the nurse sits silently next to the client for several minutes. The nurse should identify that the therapeutic communication technique of silence is used for which of the following purposes? A. To show approval of the client's desire not to talk B. To give the client time to evaluate the nurse C. To encourage the client to express feelings or concerns D. To prevent the nurse from offering a nontherapeutic response

To encourage the client to express feelings or concerns *Silence during therapeutic communication has many functions, including providing clients with time to formulate their thoughts and encouraging the expression of feelings or concerns that they wish to discuss. During silence, the client can also consider alternatives and think about what has been said

Which is a nursing goal when working with a patient with substance abuse? A. To ensure that the patient spends minimal amounts of time sleeping B. To encourage enabling behaviors in the patient's family C. To encourage the patient to eat a high-calorie diet D. To provide safe detoxification for the patient

To provide safe detoxification for the patient *When caring for the patient who has substance abuse, it is important to provide a safe and protected environment. Patients who are experiencing withdrawal from a substance may face physiologic and psychological symptoms. These may be frightening and life threatening. Enabling behaviors worsen substance abuse. A high-calorie diet may not be helpful to a patient withdrawing from drugs. The patient should sleep as much as he or she needs.

A nurse is caring for a client who has a repetitive tic that is accompanied by rapid blinking. The client occasionally repeats phrases spoken by others. The nurse should identify that these findings are an indication of which of the following disorders? A. Autism spectrum disorder B. Attention deficit hyperactivity disorder C. Oppositional defiant disorder D. Tourette's disorder

Tourette's disorder *The nurse should suspect that this client has Tourette's disorder, which can include more than 1 motor tic along with vocal tics (e.g. repeating phrases of others or barking.)

A nurse in a rehabilitation center is collecting data from a client who is being admitted for alcohol use disorder. The client states, "My last drink was 8 hours ago." Which of the following manifestation indicates that the client is experiencing withdrawal from alcohol? A. Sleepiness B. Tremors C. Hypothermia D. Diarrhea

Tremors *A client who has alcohol use disorder can experience manifestations of withdrawal within 6 to 8 hours following their last drink. The classic sign of withdrawal is mild tremors. Other manifestations of withdrawal agitation, lack of appetite, nausea, insomnia, impaired cognition, hypertension, tachycardia, and hyperthermia

A nurse is reinforcing teaching with the guardian of a client who has bipolar disorder and a new prescription for olanzapine. Which of the following adverse effects should the nurse instruct the guardian to report to the provider? A. Hypertension B. Tremors C. Ringing in the ears D. Pain with urination

Tremors *Olanzapine can cause extrapyramidal symptoms (EPS). The nurse should reinforce with the guardian to report manifestations indicating the development of EPS such as bradykinesia, mask-like facies, tremors, rigidity, a shuffling gait, drooling, stopped posture, or spasm of the muscles of the tongue, face, neck, or back

The nurse is caring for a patient with Alzheimer disease (AD) who wakes up moaning and frightened in the middle of the night. She begs that her husband's coffin be removed from her room. How should the nurse respond? A. Turn light on and say, "There is no coffin here. This is the dresser." B. Leave the light off and shine a flashlight on the dresser and say, "See! No coffin!" C. Turn the light on, assist patient to the bathroom, and say, "This is your dresser." D. Leave the light off and say, "You are in your room."

Turn the light on, assist patient to the bathroom, and say, "This is your dresser." *Turning the light on helps reorient the patient. Distraction of going to the bathroom ad identifying the dresser assist with reorientation after a frightening illusion. The other options would lead to greater confusion

A nurse is collecting data on a client who antisocial personality disorder. Which of the following manifestations should the nurse expect in the client's personality? A. Unconcerned about obeying the law B. Suspicious of others C. Unsociable with peers D. Requires excessive admiration

Unconcerned about obeying the law *A client who has antisocial personality disorder is deceitful and manipulative and lacks empathy for others. Clients who have antisocial personality disorder are risk takers, show a lack of responsibility for their actions, and frequently disobeys the law

A patient has been taking lithium for 5 days. The nurse notes his gait is a little unsteady with a walker, and he complains of thirst and insomnia. Which finding is most important for the nurse to report? A. Manic behavior B. Unsteady gait C. Thirst D. Insomnia

Unsteady gait *While all findings should be reported, uncoordinated movement is a sign of lithium toxicity and the priority finding. The patient is likely taking lithium to treat manic behavior. Thirst and insomnia are expected side effects of lithium and not indicative of toxicity

The nurse is caring for an older adult patient with a history or anxiety. Which complaint could indicate that the patient may actually be experiencing emotional distress? A. Upset stomach B. Heightened tooth sensitivity C. Unpleasant taste in mouth D. Dizziness

Upset stomach *The older adult population often expresses somatic complaints rather than openly verbalizing emotional distress. You may observe the anxious older adult complaining of an upset stomach. Inability to sleep, fatigue, or increased need to urinate

A nurse is talking with a client who reports experiencing increased stress because a new partner is "pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." Which of the following recommendations should the nurse make to promote a change in the client's situation? A. Learn to practice mindfulness B. Use assertiveness techniques C. Exercise regularly D. Rely on the support of a close friend

Use assertiveness techniques *Assertive communication allows the client to assert their feelings and then make a change in the situation *Mindfulness is appropriate to decrease the client's stress. However, it does not promote a change in the client's situation *Regular exercise is appropriate to decrease the client's stress. However, it does not promote a change in the client's sitation *Social supprt is appropraite to decrease the client's stress. However, it does not promote a change in the client's situation

A nurse is caring for a client who is having an acute panic attack. Which of the following actions should the nurse take? A. Speak to the client in a raised voice B. Walk the client to the dayroom C. Use repetition when speaking with the client D. Secure the client in his room alone

Use repetition when speaking with the client *A client who is having a panic attack might have a hard time understanding what the nurse is saying. Using simple phrases and repetition are effective methods of communication

A nurse is caring for a client who has post-traumatic stress disorder (PTSD) and who is undergoing eye movement desensitization and reprocessing (EMDR) therapy. The nurse should identify that EMDR includes which of the following strategies? A. Exposes the client to circumstances that trigger the PTSD B. Assists the client with behavioral modification C. Encourages the client to visualize a relaxing scene when traumatic memories occur D. Uses stimuli to change how the client processes the trauma

Uses stimuli to change how the client processes the trauma *EMDR uses stimuli such as tapping, eye movements, or audio sounds combined with verbalization of the traumatic event by the client. While the client recalls the traumatic event, these stimuli create neurological and physiological changes in how the client integrates the memories. EMDR is a type of psychotherapy carried out during several sessions by a therapist who is trained in the method

An elderly patient with mild dementia has demonstrated ability to feed himself, perform toileting independently, and dress himself; however, he frequently says, "You do it for me." What should the nurse do to encourage independence? A. Instruct him to try first, and then come back later to see what he has accomplished B. Verbally coach him through the task and observe his performance C. Point out to him that he needs to be independent for as long as possible D. Ask him why he frequently does not want to do things for himself

Verbally coach him through the task and observe his performance

You observe that a patient with mild dementia has difficulty buttoning a shirt. Which nursing intervention is appropriate? A. Verbally coach the patient using simple direction B. Leave the patient alone and give extra time and privacy C. Have the nursing assistant help the patient get dressed D. Give the patient a shirt with Velcro fasteners

Verbally coach the patient using simple direction *The patient needs repetitive coaching to perform the task. This may be more time consuming than simply putting the shirt on them but allowing as much independence in tasks as possible increases self-esteem. (2) If the patient is left alone, it is unlikely that they will dress themself. (3) Having the nursing assistant dress the patient is marginally better than doing it yourself, but both you and the nursing assistant should try to coach the patient to do things for themself. (4) Velcro fasteners help if fine motor skills are the issue.

You are admitting a young adult with a tentative diagnosis of bulimia. Which behavior do you anticipate? A. Vomiting after eating large quantities of food B. Obsessing over exercising constantly C. Stating suicidal thoughts to others D. Cutting food on the plate into tiny bites

Vomiting after eating large quantities of food *Bulimia involves vomiting after eating large quantities of food. (2) The patient with anorexia nervosa frequently performs excessive exercise because they believe that they are overweight. (3) Nurses should always be vigilant for suicidal ideations, but from the information given this is not the highest priority at this time. (4) Cutting food into tiny bites is more characteristic of the patient who has anorexia nervosa.

The nurse notes that newly admitted patient with Alzheimer disease (AD) has significant anomia. Which intervention is most appropriate for this problem? A. Frequently reorient the patient to his room location B. Remind the patient about the names and uses for particular items C. Assist the patient with all meals D. Wait patiently for the patient to find the word he wants

Wait patiently for the patient to find the word he wants *Anomia is the inability to recall a word. Waiting for the patient to remember the word or be able to substitute another is more supportive than supplying the word for him

A nurse is assisting with planning recreational activities for a young adult client who has an acute exacerbation of schizophrenia. Which of the following activities should the nurse recommend for this client? A. Walking with a staff member B. Playing ping-pong in the dayroom with another client C. Playing basketball with other clients in the gym D. Riding on a stationary bike alone in the fitness room

Walking with a staff member *The nurse should plan to encourage the client to participate in nonthreatening, noncompetitive physical activities. Walking with the staff also provides an opportunity for verbal interaction between the client and the staff

A nurse is caring for a client who has delirium. Which of the following items should the nurse use to promote optimal cognitive function for this client? A. Identification bracelet B. Menu for the cafeteria C. Map of the facility D. Wall calendar

Wall calendar *A wall calendar can offer a client who is experiencing delirium environmental cues for reorientation and memory

A nurse is collecting data from a client who has panic disorder and has been taking paroxetine. Which of the following assessments should the nurse identify as an adverse effect of the medication? A. Peripheral edema B. Chest congestion C. Shuffling gait D. Weight gain

Weight gain * Weight gain is an expected adverse effect of paroxetine and other SSRIs. Other adverse effects include nausea, headaches, insomnia, and sexual dysfunction

Symptomatology related to cessation of drug A. Abuse B. Psychological dependence C. Addiction D. Tolerance E. Withdrawal

Withdrawal

A nurse in an acute mental health facility is assisting with planning care for a client who has dissociative fugue. Which of the following interventions should the urse recommend? A. Reinforce with the client to recognize how stress brings on a personality change in the client B. Repeatedly present the client with information about past events C. Make decisions for the cliient on grounding techniques D. Work with the client on grounding techniques

Work with the client on grounding techniques *Grounding techniques (stomping the feet, clapping the hands, or touching physical objects) are useful for clients whp have a dissociative disorder and are experiencing manifestations of derealization *The client who has dissociative identity disorder displays multiple personalities, while the client who has dissociative fugue has amnesia regarding their identity and past *Avoid flooding the client with information about past events, which can increase the client's level of anxiety *Encourage the client to make decisions regarding routine daily activities in order to promote improved self-esteem and decrease the client's feelings of powerlessness

When a patient is showing signs of severe anxiety and it is time for him to bathe and dress, it is best if the nurse A. leave the patient alone B. asks the patient why he is feeling so anxious C. explains the rationale for practicing good hygiene D. gives simple directions

asks the patient why he is feeling so anxious

A patient is experiencing acute delirium with confusion related to medication side effects. What is the best environmental intervention to use with this patient? A. Turn on a favorite program to provide a familiar distraction B. Ask several family members to come and talk about everyday topics C. Put the patient close to the nurses' station with the door open D. Assign a nursing student to observe 1-to-1 in a quiet room

assign a nursing student to observe 1-to-1 in a quiet room

A nurse is caring for a client who has been taking lithium for the past several months. Which of the following findings should the indicate that the client is experiencing advanced lithium toxicity? A. Increased thirst B. ataxia C. Diarrhea D. Fine hand tremors

ataxia *The nurse should identify that ataxia, which is the lack of coordination of body movements, is a manifestation of advanced lithium toxicity. Other manifestations can include seizures, blurred vision, severe hypotension, large output of dilute urine, and clonic movements as signs of advanced lithium toxicity. The nurse should notify the provider immediately if these symptoms occur

A nurse is assisting with the planning of a therapeutic support group for individuals who have bulimia nervosa. Which of the following tasks should the nurse include during the orientation phase of group development? A. determine the rules that the group will follow B. address disagreements among group members C. help clients work through the grief response D. transition from the role of leader to facilitator

determine the rules that the group will follow *during the orientation phase of group development, the nurse should determine the rules that apply to the group and ensure that all members understand these rules. Examples of rules to be discussed include confidentiality and meeting times.

The patient is prescribed memantine (Namenda). Common side effects to instruct the patient about are: A. insomnia, nervousness, and anxiety B. weight gain, increased thirst, and gastrointestinal upset C. blurred vision, dizziness, and hypotension D. gastrointestinal bleeding, anorexia, and nausea

gastrointestinal bleeding, anorexia, and nausea

An MAO inhibitor such as phenelzine (Nardil) may cause life-threatening A. respiratory distress B. gastrointestinal bleeding C. cardiac arrhythmias D. hypertensive crisis

hypertensive crisis

Two serious long-term results of smoking nicotine that may occur are A. addiction to nicotine and impaired coordination B. low blood pressure and cardiac arrhythmias C. stained teeth and bad breath D. lung cancer and emphysema

lung cancer and emphysema

Which assessment should the nurse perform to prevent a life-threatening complication of CNS stimulant withdrawal? A. observe frequently for respiratory distress B. monitor for cardiac dysrhythmias C. monitor urinary output D. watch for bleeding signs

monitor for cardiac dysrhythmias

The nurse is caring for a patient with a history of substance abuse. What is the most important intervention in the treatment of the substance-dependent patient? A. careful detoxification procedures B. sympathetic care by all health professionals C. medical diagnosis of dependence on the substance D. regular participation in a 12-step program

regular participation in a 12-step program

The patient is taking an antipsychotic medication, fluphenazine (Prolixin). Which side effect, if noted, should the nurse identify as most significant, requiring immediate intervention? A. A fixed upward gaze B. A shuffling gait C. Tapping of the foot D. Irritability

shuffling gait