Exam 2 MH prep u CHAPTER 7,8,9,10,11,12,23

If the client provides a literal explanation of a proverb and cannot interpret its meaning, which thought process is lacking? Abstract thinking Concentration Memory Concrete thinking

Abstract thinking Explanation: The question asks which ability is lacking, or absent, in the client who can provide only the literal meaning of a proverb. This client is exhibiting concrete thinking but not abstract thinking, making abstract thinking the correct answer. To evaluate reasoning, the nurse can ask the client to interpret a common proverb such as "A stitch in time saves nine." The client demonstrates abstract thinking by being able to state the metaphorical meaning of the proverb (i.e., "a little planning ahead saves a lot of time and trouble later on"). - Concrete thinking occurs when a client gives a literal translation. - Concentration relates to the ability to stay on task. - Memory is recall of past events.

A client who recently immigrated from Eastern Europe comes to the clinic for an evaluation. During the assessment, the nurse notes that the client has adopted the local area's mannerisms and dress. The nurse interprets this as what? Cultural competence Linguistic competence Cultural identity Acculturation

Acculturation Explanation: The client is exhibiting acculturation, the socialization process by which minority groups learn and adopt selective aspects of the dominant culture. - Cultural identity refers to the set of cultural beliefs with which one looks for standards of behavior. - Linguistic competence is the capacity to communicate effectively and convey information that is easily understood by diverse audiences. (năng lực ngôn ngữ) - Cultural competence is a set of skills that respect and respond to the health beliefs, practices, and cultural and linguistic needs of diverse clients to bring about positive health care outcomes.

A client with schizophrenia will not take medication because the client is gaining weight. This client is exercising which ethical principle? Nonmaleficence Justice Autonomy Paternalism

Autonomy Explanation: This client is executing the right to self-determination in making personal decisions. Nonmaleficence is the duty to cause no harm, both for the individual and for all. Justice is faithfulness to obligations and duties. Paternalism is the belief that knowledge and education authorize professionals to make decisions for the good of the client.

A 75-year-old client recently experienced their partner passing away. The client is socially isolating and has not seen any friends or family in 3 weeks. Which priority question should the nurse ask the client? "How have you been feeling lately?" "Who is in your social support network?" "How are you sleeping at night?" "Are you having any thoughts of suicide or harming yourself?"

"Are you having any thoughts of suicide or harming yourself?" Explanation: Bereavement ( lost someone is loved) can be a highly stressful time with increased physical and psychological demands. During the funeral and shortly after, the community and social support network of the client are usually high. After that settles down, loneliness can set in and during this time, the person is at high risk for suicide. The client is socially isolating and is at high risk for suicide. Therefore, the priority question made by the nurse is to ask, "Are you having any thoughts of suicide or harming yourself?" The other questions, "How have you been feeling lately?", "How are you sleeping at night?", and "Who is in your social support network?", are important to ask but after a suicide risk assessment.

A client with a recent history of violence is admitted to a mental health facility for treatment. Which client statement indicates to the nurse that the client uses aggressive behavior to achieve a goal? "He provoked me to punch him." "Breaking windows is the only way anyone pays any attention to me." "She kept saying something that she knows pushes my buttons." "That man continues to nag me and I can't stand it anymore."

"Breaking windows is the only way anyone pays any attention to me." Explanation: Instrumental aggression is a goal-directed aggressive behavior that is premeditated and unrelated to immediate feelings of frustration or threat. It is a means to secure a goal or a reward. The breaking of windows to get someone to pay attention to the client is an example of instrumental aggression. Being provoked, nagged, or aggravated would cause impulsive aggression, which occurs in situations of anger and anxiety. The client just lashes out without a plan or premeditation to act aggressively.

A 10-year-old client diagnosed with conduct disorder is currently in the stabilization phase of care. Which client outcome would be appropriate in the stabilization phase? "Verbalize feelings within 2 to 3 days." "Demonstrate development of relationships with peers." "Demonstrate effective problem-solving and coping skills." "Learn problem-solving process within 2 to 3 days."

"Demonstrate effective problem-solving and coping skills." Explanation: Client outcomes vary depending on the phase of care that the client is currently in. In the immediate phase of care, outcomes are short term and focus on the immediate needs of the client. The outcomes, "Verbalize feelings within 2 to 3 days", and "Learn problem-solving process within 2 to 3 days" are appropriate in the immediate phase of care. The stabilization phase focuses on educating and empowering the client. The outcome, "Demonstrate effective problem-solving and coping skills" is appropriate in the stabilization phase of care. Finally, in the community phase of care, the outcomes are long term. The outcome, "Demonstrate development of relationships with peers" is appropriate in the community phase of care.

An adult child brings their parent to the clinic and tells the nurse that their parent has begun to act strangely in the past few days, with unprovoked outbursts of anger. After the incidents, the parent expresses remorse for their outburst. The adult child says, "I've never seen my parent act this way." Which question is most appropriate for the nurse to ask next? "Has your parent exhibited previous problems expressing anger appropriately?" "Has your parent suffered any traumatic injury to their brain recently?" "Has your parent injured the back of the irhead or neck in the past week?" "Does your parent have a history of an anxiety disorder, such as panic disorder?"

"Has your parent suffered any traumatic injury to their brain recently?" Explanation: Asking about injury to the brain would be most appropriate because the limbic system and cerebral cortex are the brain structures most frequently associated with aggressive behavior. Clients with a history of damage to the cerebral cortex are more likely to exhibit increased impulsivity, decreased inhibition, and decreased judgment than are those who have not experienced such damage. Schizophrenia and substance use disorders are also associated with violent behavior. Asking about previous problems with anger would be important to know but would not be the priority. Additionally, the person states that the parent has never done this before. Injury to the back of the head or neck is not associated with aggression.

The nurse is caring for a young adult client post exploratory laparotomy. The health care provider informs the client that there was extensive cancer and there is no treatment recommended. The client laughs and says, "they must have the wrong room, only old people get cancer." The nurse applies insight into the grief process by making which statement? "Unfortunately, young people can get cancer too." "Hearing something like this can be difficult; why don't I sit with you for a while." "I have some information about palliative care to share with you when you are ready." "I am sorry that this is not a joke; it is really serious."

"Hearing something like this can be difficult; why don't I sit with you for a while." Explanation: When loss occurs, especially if it is sudden and without warning, the cognitive defense mechanism of denial acts as a cushion to soften the effects. Typical verbal responses deny the reality of the situation and express disbelief in the information. Complete denial can be a useful when someone first experiences a traumatic loss. Acknowledging the difficulty of the experience and offering an attentive presence is the most therapeutic action until the client is ready to process reality.

A community care nurse is visiting a client at home. The client was discharged from the hospital one week ago after having a mastectomy. After the nurse completes the physical examination, the nurse asks, "How are you feeling about your body changes?" The client tells the nurse she is not interested in talking right now and would prefer that the nurse leave. Which is the nurse's most effective use of communication skills? "It would be beneficial for you to connect with other people who have had this surgery." "I can sit with you here so that you don't feel alone." "Have I said something to offend you?" "I just want you to know that I am available to talk when you are feeling up to it."

"I just want you to know that I am available to talk when you are feeling up to it." Explanation: The client is demonstrating adaptive denial in that she is gradually adjusting to the loss. The nurse should use a simple, nonjudgmental statement to acknowledge the client's loss, such as, "I just want you to know I am available to talk when you are feeling up to it." Effective communication skills can be useful in helping the client in adaptive denial move toward acceptance.

The nurse is caring for a group of clients in a treatment and recovery facility. Which client statement(s) does the nurse determine best shows motivation for recovery? Select all that apply. "I need to please others and to have them like me as a person." "I make choices based on my personal goals." "I like to make my own decisions." "I like having my own space and independence in my relationships." "I need others around me to help keep me on track."

"I like to make my own decisions." "I make choices based on my personal goals." "I like having my own space and independence in my relationships."

A parent of a child with poor impulse control is being counseled in an outpatient setting to adopt socially acceptable behavior. Which statement made by the parent demonstrates effective understanding?

"I will encourage my child to be age-appropriate independent." Explanation: As a child matures, they are expected to develop impulse control and socially acceptable behavior. Positive relationships with parents, teachers, and peers; success in school; and the ability to be responsible for oneself foster the development of these qualities. Therefore, the parent's statement, "I will encourage my child to be age-appropriate independent," demonstrates effective understanding. The parent statements, "I should be isolating my child until their learn better impulse control," "I will do everything for my child so they can focus on better behavior," and "I will punish my child when they behave poorly," do not support better impulse control or socially acceptable behavior.

he parents of a 15-year-old adolescent report that their child is behaving abnormally. After obtaining the history of the client, the nurse responds by telling the parents that their child's behavior is normal for his age. What would the parents have told the nurse regarding their child? Select all that apply. "Our child has difficulty learning and understanding concepts." "Our child is an extreme pessimist and tends to stay away from everybody." "Our child has no friends at school." "Our child spends more time playing than studying." "Our child doesn't listen to us, preferring to listen to friends."

"Our child spends more time playing than studying." "Our child doesn't listen to us, preferring to listen to friends." Spending more time playing than working indicates an erratic work-leisure pattern behavior that is common among adolescents. Giving more importance to friends indicates the adolescent's eagerness to seek peer approval; this behavior is also acceptable in adolescents. Having no friends and poor peer relationships is not a normal adolescent behavior. Having difficulty learning and understanding concepts indicates that the child has a learning disability. Extreme pessimism and social withdrawal indicate abnormal behavior in adolescents.

the nurse is admitting a client to the hospital. The nurse gives the client information about patient rights while in the hospital. Which statement by the client indicates that more teaching is needed? "You can not give any information to anyone unless I agree." "I can get a copy of my medical record if I want to read it." "You can not tell a caller that I am in the hospital." "The doctor can copy my information and send it to my son."

"The doctor can copy my information and send it to my son." Explanation: Privacy refers to that part of an individual's personal life that is not governed by society's laws and government intrusion. Protecting an individual from intrusion is a responsibility of health care providers.

An intensive-care unit (ICU) nurse is taking a self-reflection inventory related to death, dying, and grieving in their career. Which question should the nurse reflect on to increase self-awareness? "What are the losses in my life and how do they affect me?" "How can I overcome my current challenges?" "What are my career goals?" "How has my previous nursing experience affected my current abilities?"

"What are the losses in my life and how do they affect me?" Explanation: Ongoing self-reflection for nurses is an effective method of keeping the therapeutic relationship goal-directed and acutely attentive to the client's needs. The nurse's question, "What are the losses in my life and how do they affect me?", is an example of a self-reflective question related to death, dying, and grieving. The nurse's questions, "How can I overcome my current challenges?", "What are my career goals?", and "How has my previous nursing experience affected my current abilities?" is reflective, but not related to grief.

A new nurse asks the nurse manager about the best intervention to use when trying to de-escalate a potentially violent client. Which response would be most appropriate? "What works best is what fits the client and the situation." "You need to confront the client to show you are in charge." "Make sure that another colleague knows where you are at all times." "I've always had good results with medications."

"What works best is what fits the client and the situation."

In which ways can anticipatory grief be helpful for the client and family? Admission to hospice care Acceptance of impending death An earlier and less painful death Clear examination of treatment options

Acceptance of impending death Explanation: Anticipatory grief allows the individual and others to get used to the reality of the loss or death and to complete unfinished business. similar to the normal process of mourning, but it happens before the actual death.

The nurse who is preparing a Native American client for surgery notes that the client is wearing a medicine bag. What intervention should the nurse implement to best address the client's spiritual needs with respect to presurgical care needs? Ask the client how the medicine bag can be respected while preparing for surgery. Remove the medicine bag and give it to a family member for safe keeping. Ask the client to provide information about his or her personal spiritual belief system. Explain to the client that the medicine bag must be removed in order to minimize the risk of infection during the surgical procedure.

Ask the client how the medicine bag can be respected while preparing for surgery. Explanation: Nurses who are unsure of a person's social or cultural preferences need to ask the client directly during the initial encounter about preferred terms of address and ways the nurse can help support the client's spiritual, religious, or health practices. None of the remaining options demonstrates respect and interest in the client's spiritual needs related to the medicine bag.

A physician would like to include a client with schizophrenia in a research study testing a new medication. The nurse's obligation is to do what? Talk the client out of revoking consent once the study has started. Persuade the client to consent, because the new drug has shown promising results. Obtain informed consent when the primary provider cannot be present. Assess the client's legal capacity when that client is asked to give consent.

Assess the client's legal capacity when that client is asked to give consent. Explanation: The nurse serves as the client's advocate, the team's colleague, and the facility's excellent employee by continually evaluating the client's ability to give informed consent and his or her willingness to participate and continue with a treatment modality. Unless serving as the primary provider, the nurse is not responsible for obtaining informed consent. That is the role of the primary provider.

A psychiatric mental health facility is undergoing a change from paper-based health records to electronic records. What action should the nurse prioritize in order to ensure client rights are protected? Teaching clients that they may lose the right to view their health records under the new system Being vigilant to identify any potential threats to client confidentiality Ensuring clients know that they have the right to opt out of the proposed system Educating clients and families about the potential benefits of the new system

Being vigilant (carefully) to identify any potential threats to client confidentiality Explanation: Electronic health records present potential threats to confidentiality that must be addressed. It would not be possible for a client to opt out of a documentation system. Teaching clients about the benefits of health records does not directly address client rights. Clients never lose the right to view their health records.

The nurse decides to place an aggressive and violent client in mechanical restraints. The nurse bases this decision on what? Court order Physician's order Client's mood Client's safety

Client's safety Explanation: The use of restraints is warranted only when the client's safety is in jeopardy and other, less restrictive measures have not been effective. The nurse does not base the decision on the client's mood or court order. Just because there is a physician's order for use of restraints, this does not mean that they are appropriate in every situation; this is based on nursing judgment.

A client has lost emotional and physical control. The client is shouting, screaming, hitting others, and throwing objects. Which phase of the aggression cycle is this client expressing? Triggering Escalation Recovery Crisis

Crisis Explanation: The client's signs of shouting, screaming, hitting others, and throwing objects suggest that the client is in the crisis phase of the aggression cycle. This phase is characterized by loss of emotional and physical control. In the triggering phase, the client often becomes angry in response to an event or circumstance in the environment. In the escalation phase, the client may move toward a loss of control, perhaps yelling, making threatening gestures, and being unable to think clearly about the problem. In the recovery phase, the client regains emotional and physical control

A client is admitted to the behavioral health facility involuntarily. The client is scheduled to undergo electroconvulsive therapy. Which action does the nurse take before the procedure? Sign the document showing informed consent is not necessary. Ask the client to accept voluntary admission before the client gives informed consent. Ensure the client has given informed consent. Ask the client's next of kin to provide informed consent.

Ensure the client has given informed consent. Explanation: Clients who are involuntarily committed have the right to treatment, as well as the right to refuse treatment. Additionally, those who are involuntarily committed do not lose the right to informed consent. The client should be provided information on the treatment and the client should provide informed consent. The other answer choices are incorrect and do not allow the client to maintain autonomy.

During dinner time on an inpatient unit, an adolescent client throws a tray across the table. What would be an effective use of limit setting with this client? You Selected: Take the client into a quiet area for a therapy session. Correct response: Remind the client about the behavior contract.

Explanation: In order to decrease violence and increase compliance with treatment, it is important for the nurse to remind the client about the behavior contract. The contract outlines expected behaviors, limits, and rewards to increase treatment compliance. Taking the client to a quiet area during a time when the client is exhibiting violent behavior could be unsafe for the nurse and the client. A therapy session may not be helpful if the client is in a heightened emotional state. Encouraging the client to log the event in a diary is an intervention used to improve coping skills and self-esteem, not limit setting. Role-modeling how to be social during meals is an intervention used to promote social interaction, not limit setting.

A nurse is leading an anger management group in an inpatient program. A client says, "I'm feeling really tense, and I'm fidgety today." What is the nurse's most appropriate response to the client's comment?

Explore what is underlying the client's physical and emotional state Explanation: Identifying the feelings reduces the frustration. Attempt to discover the concern and respond with empathy, interest, and willingness to help. Encourage the client to describe and clarify the client's experience using open-ended questions to increase the client's awareness of problematic feelings and what triggers them

A client's plan of care includes revoking privileges for inappropriate behavior, based on a contract between the client and the nurse who wrote the plan. Another nurse decides to ignore this because the client promises that the client will adhere to the contract in the future. The second nurse's behavior may have violated which ethical principle? Autonomy Beneficence Veracity Fidelity

Fidelity Explanation: Fidelity is the nurse's faithfulness to duties, obligations, and promises. Autonomy is the client's right to make decisions for himself or herself. Veracity is a systematic behavior of honesty and truthfulness in speech. Beneficence is the principle of doing good, not harm.

A child is taking methylphenidate for treatment of attention deficit hyperactivity disorder (ADHD). Which side effect must be monitored in this child? Growth delays Weight gain Polyuria Increased appetite

Growth delays Explanation: Nursing considerations when administering methylphenidate include monitoring appetite suppression or growth delays

A nurse is caring for an adolescent with conduct disorder. The nurse tries to involve the client in discussions on age-related topics such as books, current trends, and movies. What is the nurse trying to accomplish by doing this? Teach about the relationship between behavior and its consequences. Help the client develop peer relationships. Evaluate the client's frustration tolerance. Teach the client to deal with problems. SUBMIT ANSWER Exit quiz

Help the client develop peer relationships.

A nurse is caring for an adolescent with conduct disorder. The nurse tries to involve the client in discussions on age-related topics such as books, current trends, and movies. What is the nurse trying to accomplish by doing this?

Help the client develop peer relationships. Explanation: Engaging clients with conduct disorder in conversation on age-related topics helps them practice how to interact as other adolescents do. This should help the client to develop peer relationships. This intervention is not useful for teaching clients to deal with problems, evaluating frustration tolerance, or understanding the relationship between behavior and its consequences

The nurse leads an education session regarding the effect of suppressing anger on the body. Which statement by the client indicates a need for further teaching? "Managing my anger might help my depression get better." "Being angry all the time overstimulates my nervous system." "If I figure out how to lower my anger, it's healthier for me." "I need to stop feeling angry or I won't be healthy."

I need to stop feeling angry or I won't be healthy." Explanation: Anger becomes negative when the person denies it, suppresses it, or expresses it inappropriately. Possible consequences are physical problems such as migraine headaches, ulcers, or coronary artery disease, and emotional issues such as depression and low self-esteem. It is unreasonable to expect that one will never get angry; what is important is that the anger is appropriately managed.

n clients with conduct disorder, reactivity of the autonomic nervous system is reduced. Which sign related to this physiological abnormality can be seen in clients with conduct disorder? You Selected: Unemotional behavior Correct response: Decreased social inhibitions

In clients with conduct disorder, there is a lack of reactivity of the autonomic nervous system, which results in decreased normal avoidance or social inhibitions. Decreased interest in social activities, disturbed peer relationships, and unemotional behavior may be secondary effects of such decreased levels of avoidance and social inhibition.

A child with attention deficit hyperactivity disorder (ADHD) has been prescribed dextroamphetamine. For what effects should the nurse tell the parents to monitor the child? Select all that apply. Appetite suppression Insomnia Hypotension Weight gain Weight loss

Insomnia Weight loss Appetite suppression : Explanation: Dextroamphetamine is a commonly prescribed drug to treat symptoms of ADHD. Insomnia, weight loss, and appetite suppression are the common side effects associated with this drug. The nurse should educate the parents on monitoring these effects. Hypotension and weight gain are not common side effects of this drug

A client receives a court order for commitment. Which best exemplifies the concept of "least restrictive environment"? Restraining the client with the fewest number of restraint points possible Involuntary commitment to an outpatient community mental health center Medication administration for sedation so the client cannot get out of bed Placing the client in a locked padded room in response to threats of self-harm

Involuntary commitment to an outpatient community mental health center Explanation: An example of the concept of "least restrictive environment" is involuntary commitment of a client to an outpatient mental health center. Medications cannot be given unnecessarily, such as to keep a client in bed. An individual cannot be restrained or locked in a room unless all other "less restrictive" interventions are attempted first. Although clients should be physically restrained with the fewest restraint points possible, there is no indication that this client requires restraint. Physical restraints should be applied only after all other interventions have been used and the client continues to be a danger to self or others.

Which would be the most appropriate intervention for an adolescent who is manipulative and exhibiting aggressive behaviors? Social skills training Limit setting Time out Self-esteem enhancement

Limit setting Explanation: Limit setting involves three steps: informing the client of the rule or limit, explaining the consequences if the client exceeds the limit, and stating the expected behavior.

Which drug has been effective in treating aggressive clients diagnosed with bipolar disorders? Carbamazepine Clozapine Lithium Valproic acid

Lithium Explanation: Lithium, an antimanic medication, has been effective in treating aggressive clients with bipolar disorder.

A nurse must assess for characteristics that are predictive of violent behavior. Research suggests violent behavior is influenced by possession of which attribute? Therapeutic relationship Low self-esteem Assertive behavior Mindfulness

Low self-esteem

A nursing student identifies which as the most important tool of psychiatric nursing? Clinical reasoning Self Plan of care Reflection

Self Explanation: The most important tool of psychiatric nursing is the self. Through relationship building, clients learn to trust the nurse, who then guides, teaches, and advocates for quality care and treatment.

The nurse in an psychiatric inpatient facility encourages clients to attend daily prayer sessions. What is the most likely reason for the nurse's action? Choose the best answer. Prayer helps in coping with stress. Prayer helps in curing illness. Prayer helps in improving the effectiveness of therapy. Prayer prevents the progression of the illness.

Prayer helps in coping with stress. Explanation: Religious activities such as prayer are believed to help a client cope with stress. Prayer may induce a sense of well-being in the client. Prayer may not directly cure psychiatric illnesses but can accelerate the process of healing. Prayer does not interfere in the disease progression and may not directly improve the efficacy of psychotherapy

Evaluating the cultural practices of others according to the nurse's own culture can be counteracted by the nurse's use of which practice? Self-discipline Self-disclosure Self-esteem Self-assessment

Self-assessment Explanation: Ethnocentrism, or the tendency to believe that one's own way of thinking, believing, and behaving is superior to that of others, is counteracted by the nurse's use of self-analysis. The other answers are not applicable as a counteraction to ethnocentrism.

The nurse is caring for a client who has been placed in palliative care. The nurse observes the client constantly looking at photographs from youth. According to the tasks of grieving by Rando, which task is being accomplished here? Recollect Recognize Relinquish React

Recollect Explanation: The client is being treated for cancer. The client looks at the photographs from youth that remind the client of earlier days when the client was healthy and beautiful. This indicates that the task of recollecting and reexperiencing is being accomplished. In the task of reacting, the client responds emotionally to the loss. In the task of recognizing, the client begins to develop the sense of awareness of the loss. In the task of relinquishing, the client starts accepting the loss and its influence in the client's life

During which phase of the aggression cycle does the client regain physical and emotional control? Triggering Recovery Postcrisis Escalation

Recovery

A nurse is planning to educate a client who is diagnosed with intermittent explosive disorder about self-management strategies for the condition. What topics should the nurse address while teaching this client? Select all that apply. Strategies to eliminate pain Relaxation techniques A healthy diet regimen Strategies for anger management Strategies to avoid alcohol and substance use

Relaxation techniques Strategies for anger management Strategies to avoid alcohol and substance use

During dinner time on an inpatient unit, an adolescent client throws a tray across the table. What would be an effective use of limit setting with this client? Take the client into a quiet area for a therapy session. Role-model how to be social during meals. Remind the client about the behavior contract. Encourage the client to log the event in a diary.

Remind the client about the behavior contract.

Which characteristic would be most prevalent in an individual demonstrating low self-efficacy? Self-doubt Stress management Personal goals Self-motivation

Self-doubt Explanation: Self-efficacy is a belief that personal abilities and efforts affect the events in our lives. A person who believes that his or her behavior makes a difference is more likely to take action. People with low self-efficacy have low aspirations, experience much self-doubt, and may be plagued by anxiety and depression. - People with high self-efficacy set personal goals, are self-motivated, cope effectively with stress, and request support from others when needed

Aggression control can be measured by the nurse's observation of a client's ability to do what? Use increased doses of medication to reach a desired effect Withhold his or her thoughts and feelings Display increasing motor activity Show an increased tolerance for frustration

Show an increased tolerance for frustration

Which is the most frequent and persistent bereavement-associated symptom? Headaches Impaired appetite Sleep disturbances Indigestion

Sleep disturbances Explanation: Sleep disturbances are the most frequent and persistent bereavement-associated symptom ( lost someone is loved).

A nurse is counseling the parents of a client with conduct disorder. The nurse tells them that they should be vigilant in watching for certain behaviors that their child is prone to exhibit. Which behaviors would the nurse want the parents to watch for? Select all that apply. Smoking Binge eating Suicidal tendencies Alcohol and substance abuse Early onset of sexual behavior

Smoking Alcohol and substance abuse Early onset of sexual behavior

A nurse is assessing an adolescent with conduct disorder. Which should the nurse expect to find in this adolescent? Select all that apply. The adolescent may be unwilling to speak to the nurse. The adolescent may behave disrespectfully to the nurse. The adolescent may sob because of guilt for behavior. The adolescent may have physical manifestations related to stress. The adolescent may give false reports of having a physical illness. The adolescent may make derogatory comments about parents and teachers.

The adolescent may be unwilling to speak to the nurse. The adolescent may behave disrespectfully to the nurse. The adolescent may make derogatory comments about parents and teachers. Adolescents with conduct disorder may act lazy and be unwilling to be interviewed. They may be disrespectful to the nurse and other personnel in the health care facility. They may also make derogatory comments about their parents and teachers. People with conduct disorder are very unlikely to express grief. They show no guilt or remorse associated with their acts. These adolescents are unlikely to be stressed. Clients with conduct disorder are very unlikely to behave like a hypochondriac and give false complaints of having a physical illness.

A nurse is counseling the parents of an adolescent client with oppositional defiant disorder (ODD). The parents state, "We've tried everything, what else are we supposed to do?" What is the most likely reason for the parents' voiced loss of hope? The adolescent may have been abused in childhood. The parents may have not taught appropriate behavior to the adolescent. The parents may have been pampering the adolescent too much. The adolescent may have limited sensitivity to reward and punishment.

The adolescent may have limited sensitivity to reward and punishment. Explanation: The most likely reason for the parents' sense of loss of control and hope with their adolescent child who has a diagnosis of ODD is that the client has a limited ability to make associations between a behavior and the consequences of that behavior—both negative and positive. The parents likely did not neglect to teach the client appropriate behavior. Childhood abuse may be a predisposing factor for ODD. The parents likely did not pamper the client; however, problem behaviors may have been inadvertently reinforced in the home.

A nurse is working with a child undergoing behavioral modification therapy for attention deficit hyperactivity disorder (ADHD). The nurse finds that the child is thin. What could be the most likely reason for this observation? The child finds food distasteful. The child is genetically predisposed to being thin. The child has decreased appetite. The child cannot sit through meals.

The child cannot sit through meals. Explanation: Children with ADHD are not patient enough to sit through meals. This results in reduced dietary intake. This is the most likely reason for children with ADHD to be thin. Children with ADHD do not have impaired taste sensation. These children do not have loss of appetite unless they are on drugs like methylphenidate. It is not known whether children with ADHD are genetically predisposed to being thin.

The nurse is assessing an adolescent with conduct disorder. The nurse finds that the adolescent is not interested in seeking summer employment. What is the most likely reason for the client's disinterest in getting a job? The client feels that the client is too disturbed to work. The client prefers stealing money over working for it. The client feels that depression and anxiety would interfere with working. The client feels that the client will not be efficient in the workplace.

The client prefers stealing money over working for it. Explanation: The adolescent with conduct disorder is most likely to steal money for survival instead of earning it through employment. Feeling too disturbed to be able to work and feeling that the client would be inefficient at work are not behaviors related to clients with conduct disorder. Depression and anxiety are not present in clients with conduct disorder.

Which factor will most influence a nurse's interaction with a child diagnosed with conduct disorder? You Selected: severity of the behavior Correct response: personal values regarding child rearing

The nurse's beliefs and values about raising children affect how he or she deals with children and parents. The remaining options may contribute but they are not the most influential factor.

The nurse is caring for a client who is extremely depressed after receiving a diagnosis of cancer. Which body language should the nurse adopt while speaking to the client in order to demonstrate an attentive presence? Select all that apply. The nurse should lean slightly toward the client. The nurse should stand facing the client. The nurse should sit on one side of the client. The nurse should maintain moderate eye contact while the client speaks. The nurse should keep her arms folded.

The nurse should stand facing the client. The nurse should lean slightly toward the client. The nurse should maintain moderate eye contact while the client speaks.

A client with bipolar disorder has been following the prescribed medication regimen. The client indicates to the nurse a desire to stop the medication now that the client is feeling better. The nurse tells the client that most likely the client will have to remain on the medication for life to keep the condition under control. The nurse is practicing which principle? Autonomy Veracity Fidelity Justice

Veracity Explanation: Veracity is the duty to tell the truth. In this case, the client wants to hear that the client can stop medication, but the nurse is honest and tells the client that the client will need to continue it to stay healthy.

A client asks the nurse for a date with them when they are discharged. The nurse tells the client that it is against policy to date clients. The client yells obscenities at the nurse and hits the counter before stomping away. Which defense mechanism does the nurse document that the client is using? repression denial projection acting out

acting out Explanation: Acting out is an immature defense mechanism by which the person deals with emotional conflicts or stressors through actions rather than through reflection or feelings. Rejection can lead to anger and aggression when that rejection causes the individual emotional pain or frustration, or is a threat to self-esteem. Denial is when a person refuses to accept facts; this client is experiencing rejection, so there is recognition of the reality of the situation. Repression occurs when unfavorable thoughts are ignored; this client reacts to the feeling of rejection. A client using displacement would direct their anger toward something less threatening than the stimuli. This client yelled directly at the source of their anger

A nurse is assessing a 10-year-old child who is displaying behaviors that are consistent with oppositional defiance disorder. When conducting the assessment, the nurse should also assess for which co-morbidity? schizophrenia attention deficit hyperactivity disorder cognitive impairment kleptomania

attention deficit hyperactivity disorder Explanation: Oppositional defiance disorder is often co-morbid with other psychiatric disorders that need to be treated as well. It is possible that the oppositional defiance disorder is superimposed on the attention deficit hyperactivity disorder because this problem is the underlying cause of the child's maladaptive behaviors.

The nursing instructor is discussing the Individuals with Disabilities Education Act and various disablities that have the right to education in the least restrictive environment. The instructor asks whom this applies to, clients with which problems? Which examples should the student nurse choose? Select all that apply. traumatic brain injury flu autism pneumonia orthopedic impairment

autism traumatic brain injury orthopedic impairment The right to be treated in the least restrictive environment means that an individual cannot be restricted to an institution when he or she can be successfully treated in the community. Disabilities include autism, orthopedic impairments, and traumatic brain injuries. Flu, and pneumonia are not among the problems included in the Individuals with Disabilities Education Act.

A mental-health nurse is seeking individual counseling for the death of previous clients. The nurse expresses to the therapist, "I felt like I had to hide my sadness. I felt like it wasn't acceptable to talk about my feelings." What is the nurse experiencing? depression complicated grief disenfranchised grief normal grief

disenfranchised grief Explanation: Disenfranchised grief is grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported socially. Nurses, providers, and hospital chaplains may experience disenfranchised grief when their need to grieve is not recognized. Normal grief is the grief that occurs in response to a socially acceptable loss. Complicated grief occurs when the griever is void of emotions, grieves for a prolonged period, or has expressions of grief that seem disproportionate to the event. Depression is a mood disorder that may occur with or without a loss. The nurse being counseled in the scenario felt like they had to hide their feelings of loss because the loss was not socially acceptable; therefore, the nurse is experiencing disenfranchised grief.

A psychiatric-mental health nurse utilizes ethical provisions while caring for a client diagnosed with a mental illness. Which standard of professional performance is the nurse utilizing? education evidence-based practice and research leadership ethics

ethics Explanation: The ethics standard of professional performance integrates ethical provisions in all areas of practice. The education standard attains knowledge and competency that reflect current nursing practice. The evidence-based practice and research standard integrates evidence and research findings into practice. The leadership standard collaborates with the health care consumer, family, interprofessional health team, and others in the conduct of nursing practice.

The nurse is orienting a new staff member in an inpatient mental health unit when a client begins to act in a violent manner. The nurse should explain to the new staff member that some clients use violence and aggression to ... relive their childhood experiences. practice assertiveness skills. have their needs met. be placed in their rooms by themselves.

have their needs met. Explanation: The nurse should explain to the new staff member that some clients use violence and aggression to get what they want or to force change or regain control. The client may also be seeking attention.

A nurse is working with an adolescent client with a diagnosis of conduct disorder. The nurse is helping the client reflect on a situation in which the client became aggressive and asks how the client could have handled it differently. The nurse is employing which intervention? promoting social interaction providing client education improving coping skills and self-esteem increasing treatment compliance

improving coping skills and self-esteem Explanation: Nursing interventions for conduct disorder include teaching and practicing problem-solving skills. In this scenario, the nurse is asking the client to reflect on the situation in order find healthier, adaptive solutions. Teaching and practicing problem-solving skills is aimed at the ultimate goal of improving coping skills and self-esteem for clients with conduct disorder.

The nurse is performing an assessment of a client in the behavioral health unit that is in a group session. Another client informs the group that their child died in a house fire and it has been devastating. How will the nurse document the assessment when the previous client begins smiling at the other client's loss? blunted affect inappropriate affect restricted affect flat affected

inappropriate affect Explanation: - A flat affect is exhibited by no facial expression. - A blunted affect is showing little or a slow-to-respond facial expression. - An inappropriate affect is displaying a facial expression that is incongruent with the mood or situation. - A restricted affect is displaying one type of expression, usually serious or somber.

A 21-year-old client is being evaluated in the clinic for anger management. The client describes experiencing repeated episodes lasting 20 to 30 minutes of aggressive behavior with angry verbal outbursts when feeling angry. Which diagnosis should the nurse assess for? conduct disorder (CD) intermittent explosive disorder (IED) kleptomania oppositional defiant disorder (ODD)

intermittent explosive disorder (IED) Oppositional defiant disorder (ODD) consists of an enduring pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures without major antisocial violation. Intermittent explosive disorder (IED) involves repeated episodes of impulsive, aggressive, violent behavior, and angry verbal outbursts, usually lasting less than 30 minutes. Conduct disorder is characterized by persistent behavior that violates societal norms, rules, laws, and the rights of others. Kleptomania is characterized by impulsive, repetitive theft of items not needed by the person, either for personal use or monetary gain. The client in the scenario should be evaluated for IED based on the presenting symptoms.

The nurse is assigned to care for a client who assaulted another nurse the previous day. Which behavior indicates that the nurse is having an issue providing care to the client? gives the client extra attention follows safety protocols during care limits contact with the client provides care as expected

limits contact with the client Explanation: Nurses may withdraw from angry clients and try to hide their own anger because "good nurses" do not get angry at clients. However, distancing from the client is painful and indicates the nurse is having an issue providing care to the client. The nurse should provide care as expected. Giving additional attention to the client might cause the client to act out more frequently. All nurses should follow safety protocols when providing care and this would not indicate an ongoing issue with the client.

The nurse is caring for a pediatric client diagnosed with attention-deficit/hyperactivity disorder (ADHD) who is having difficulty with school due to inattentiveness and hyperactivity. Which medication will the nurse anticipate most likely being prescribed for the client to help with these symptoms? fluoxetine olanzapine quetiapine methylphenidate

methylphenidate Medications are often effective in decreasing hyperactivity and impulsiveness and improving attention; this enables the child to participate in school and family life. The most common medications are methylphenidate and amphetamine compound. Methylphenidate is effective in 70% to 80% of children with ADHD; it reduces hyperactivity, impulsivity, and mood lability and helps the child pay attention more appropriately.

The nurse is caring for a client that is confused. The nurse, while giving the client a bed bath leaves the room to get supplies. The nurse returns to find the client on the floor with the bed in high position, and side rails down. What law has been broken? negligence beneficence non-maleficence assault

negligence Explanation: Negligence is an unintentional tort that is a breach of duty of reasonable care for a patient for whom a nurse is responsible that results in personal injuries. Assault is a threat of imminent harmful or offensive contact with a person. Beneficence is defined as an act of charity, mercy, and kindness with a strong connotation of doing good to others including moral obligation. Non-maleficence means non-harming or inflicting the least harm possible to reach a beneficial outcome. Non-maleficence, beneficence, and assault have not been breached.

The client with a history of explosive outbursts becomes angry and states, "I am really getting angry." The nurse sees this as what? controlling manipulation progress regression

progress Explanation: When the client is able to verbalize angry feelings, this is progress from having an outburst. The client is not trying to control the situation. Manipulation occurs when a person tries to persuade another to act in a desired way. Regression occurs when one retreats to an earlier level of functioning and developmen

A pediatric client has a history of repeated, intentional fire-setting behaviors. Which diagnosis should the client be assessed for? pyromania intermittent explosive disorder (IED) oppositional defiant disorder (ODD) kleptomania

pyromania Explanation: Oppositional defiant disorder (ODD) consists of an enduring pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures without major antisocial violation. Pyromania is characterized by repeated, intentional fire setting. Kleptomania is characterized by impulsive, repetitive theft of items not needed by the person, either for personal use or monetary gain. Intermittent explosive disorder (IED) involves repeated episodes of impulsive, aggressive, violent behavior, and angry verbal outbursts, usually lasting less than 30 minutes. With the presenting symptoms, the client in the scenario should be further assessed for pyromania

A nurse notifies a client of the death of a parent after a motor vehicle crash. Which physical symptom(s) assessed by the nurse correlates with the immediate grieving process? Select all that apply. respiratory rate of 32 and difficulty breathing lack of strength and feels weak states, "I feel a burning sensation in my upper chest area." difficulty with urinating reports a frontal headache

respiratory rate of 32 and difficulty breathing states, "I feel a burning sensation in my upper chest area." lack of strength and feels weak A client experiencing acute physical symptoms at the time of notification of the loss of a loved one can have symptoms of shortness of breath, indigestion, and a lack of muscular power or strength. The nurse would need to be aware of these as immediate effects that can occur. The client may have a headache due to stress, but this is not typically an immediate reaction. Difficulty with urinating is not typically a physical response to the loss of a loved one.

The disaster triage nurse is caring for a family who lost their home, vehicles, and personal items due to a fire. Several of the family members have minor injuries. The nurse develops a treatment plan based on Maslow's hierarchy of needs. Which intervention does the nurse address first? securing a place to sleep and meals for the next few days arranging an opportunity for the children to play with their friends ensuring the parents have transportation to work anticipating the family will grieve the loss of personal items

securing a place to sleep and meals for the next few days Explanation: Maslow's hierarchy of needs begins with physiologic needs (food, air, water, sleep), then progresses to safety needs (a safe place to live and work), and security and belonging needs (satisfying relationships), followed by self-esteem needs (adequacy and confidence and ending with self-actualization (ability to realize one's full innate potential). This family is experiencing a significant loss and the first action is the securement of a place to rest and food to eat. Until these needs are met, the family may not be ready to process securing the remaining needs.

A 13-year-old client is being assessed by the psychiatric-mental health nurse. Upon assessment, the client reveals that they believe that the world is aggressive and threatening and they respond likewise. Which aspect of the assessment would the nurse document the findings in the medical record? self-concept mood and affect thought process and content general appearance and motor behavior

thought process and content Explanation: An assessment consists of multiple components. Within the general appearance and motor behavior component, the nurse assesses the client's appearance, speech, and motor behavior. These aspects are typically normal for the age group but may be somewhat extreme (e.g., body piercings, tattoos, hairstyle, clothing). These clients often slouch and are sullen and unwilling to be interviewed. They may use profanity; call the nurse or provider names; and make disparaging remarks about parents, teachers, police, and other authority figures. Within the mood and affect components, the nurse assesses the client's emotions and facial expressions. Irritability, frustration, and temper outbursts are common. Within the thought process and content section, the nurse assesses the client's thinking patterns and worldview. In this section, the client may perceive the world to be aggressive and threatening, and they respond likewise. Clients may be preoccupied with looking out for themselves and behave as though everyone is "out to get me." Finally, within the self-concept section, the nurse assesses the client's self-esteem, which is typically low. In the scenario, the nurse would document the findings in the thought process and content section of the assessment.

A client with a history of violence is demonstrating signs of agitation. Which communication technique(s) will the nurse use to deescalate the situation? Select all that apply. validation observation seek information false reassurance client partnership

validation observation client partnership seek information

A psychiatric-mental health nurse is assessing an 11-year-old child experiencing problems with emotional regulation. Which assessment finding would the nurse document as internalizing behavior? You Selected:

withdraw Explanation: Children respond in different ways to environmental pressures and adversity. Some children externalize their emotional issues by directing anger and frustration into aggressive or delinquent behavior, putting them at risk for diagnoses of oppositional defiant disorder (ODD) and conduct disorder (CD). Other children experiencing the same pressures may internalize their emotions, resulting in somatic concerns, withdrawal, isolative behavior, and problems with anxiety and depression. These behavioral patterns correspond to the problems with self-regulation of emotions (internalizing) and behavior (externalizing). Vandalism, threatening, and demanding are categorized as externalizing behavior, whereas withdraw is categorized as internalizing behavior

The nurse has been working with a client to develop self-efficacy. What client statement would most likely suggest to the nurse that self-efficacy is improving? "Situations that others find stressful don't really bother me." "I don't come down with colds anymore when I'm under stress." "I have a group of good friends I can rely on." "I have decided to apply for a promotion at work."

"I have decided to apply for a promotion at work." Explanation: Self-efficacy is the belief that one's own actions and abilities impact the events in one's life. Clients with high self-efficacy are more likely to set goals and take actions to achieve those goals. A client who has set a goal of achieving a promotion at work and taken the action to apply for the promotion is demonstrating self-efficacy.

A female client of Arab descent comes into the clinic with depression. The client states, "I am a burden and failure as a woman in my culture." Which question by the nurse is priority? "Do you enjoy activities anymore?" "Are you having thoughts of harming yourself or of suicide?" "When is the last time you tried talking to your family about this?" "Are you feeling depressed now?"

"Are you having thoughts of harming yourself or of suicide?" Explanation: Clients in an underrepresented culture experience high stigmatization. Clients who are depressed and live within a highly stigmatized culture are at high risk for suicide. The client's statement is expressing feelings of worthlessness, which may indicate potential suicidal ideations. The nurse must directly ask the client if they are thinking about harming themselves or of suicide. The remaining questions of asking about current depressed feelings, speaking to their family about their feelings, and enjoying activities may be part of the assessment, but only after establishing that the client is safe and free of suicidal ideations.

The nurse begins an assessment of an older adult client who was brought to the hospital by her son. The client states, "I don't want your kind of help." What is the nurse's best response? "Have you had a bad experience in the hospital before?" "You don't think I know what I'm doing?" "What makes you think you're not sick?" "What kind of help do you think you need?"

"Have you had a bad experience in the hospital before?" Explanation: If the client is reluctant to engage with the nurse for the assessment, it is likely due to a previous unsatisfactory experience with the health care system. A sign that the client is reluctant is that the client was brought to hospital by a family member. The nurse must address the client's feelings and perceptions to establish a trusting working relationship before proceeding with the assessment.

An emergency department nurse cares for a client. At the initial meeting, which statement made by the nurse demonstrates diversity acceptance of the client? "How would you like to be cared for?" "Why are you in the hospital?" "What is your name?" "Hi. I am your nurse, and I will be caring for you today."

"How would you like to be cared for?" Explanation: To provide care, the nurse must find out as much as possible about a client's values, beliefs, and health practices. Often, the client is the best source of information, so the nurse must ask the client what is important to them, such as "How would you like to be cared for?" or "What do you expect (or want) me to do for you?". Therefore, the nurse statement, "How would you like to be cared for", demonstrates diversity acceptance in the initial interview. "Hi. I am your nurse, and I will be caring for you today", "What is your name?", and "Why are you in the hospital" does not demonstrate curiosity toward the individual client and their preferences.

A nurse is completing the initial interview with a newly admitted client. What statement made by the nurse would be most appropriate to get to know the client better in the initial interview? "You are welcome to ask any questions that you may have." "How would you like to be cared for?" "Have you been in a facility like this before?" "Would you like a tour of your room and the unit?"

"How would you like to be cared for?" Explanation: To provide care, the nurse must find out as much as possible about a client's values, beliefs, and health practices. Often, the client is the best source for that information, so the nurse must ask the client what is important to them. The nurse's question, "How would you like to be cared for?" is an accepting and nonjudgmental approach to inquire about the client's preferences; therefore, it would be the most appropriate in the initial interview. The nurse's questions, "Have you been in a facility like this before?", and "Would you like a tour of your room and the unit?" could be asked after the client has been greeted appropriately and assessed. The nurse's statement, "You are welcome to ask any questions that you may have" is generic and not client centered.

The nurse has entered a hospital client's room and asked the client if the client plans to attend the morning's scheduled group life-skills session. Which response should signal the presence of thought blocking to the nurse? "Warning, warning, watch your back." The client makes eye contact with the nurse but does not respond verbally. "I might. I'll give it some..." "Well, that's certainly the end of that."

"I might. I'll give it some..." Explanation: Blocking refers to a sudden stoppage in the spontaneous flow or stream of thinking or speaking for no apparent external or environmental reason. Clanging involves perceived similarities in meaning between words of similar sound ("morning"; "warning"). Mutism is the absence of a verbal response.

A psychiatric-mental health nurse is teaching a parent of a child diagnosed with conduct disorder. Which statement made by the parent indicates a need for further teaching? "I will suppress my problems and not burden others with what I am going through." "I will not try to rescue my child." "I will implement age-appropriate activities and expectations." "I will enforce effective limit-setting techniques."

"I will suppress my problems and not burden others with what I am going through."

The nurse is caring for a client in an inpatient behavioral health facility. The client is determined to be mentally competent. Which client statement(s) does the nurse identify as best displaying self-determinism? Select all that apply. "What can I get in return for taking medication to treat my condition?" "I will be judged as being crazy if I take the medication to treat my condition." "I will be using an alternative treatment instead of your treatment plan." "I would like a referral to get another opinion." "I choose to not stay in the facility and not get treatment right now."

"I would like a referral to get another opinion." "I will be using an alternative treatment instead of your treatment plan." "I choose to not stay in the facility and not get treatment right now." "I will be judged as being crazy if I take the medication to treat my condition."

The nurse explains to a client how important it is that the client is eating properly even though the client is in a personal crisis over the loss of a loved one. The client wants to know why this matters. What is the nurse's best response? "Eating regular meals gives you something to focus on." "Not eating will make your other family members worry about you." "You can spend some time during meals with your other family members." "It is important to give your body nutrition to manage this crisis."

"It is important to give your body nutrition to manage this crisis." Explanation: The client in crisis needs nutrition to have the physical resources to manage a crisis- in this case, the loss of a loved one. Having a crisis affects a client by being physically exhausting and the client needs nutritional stores to help reduce the potential for injury. Eating regular meals will give the client something to focus on, and the client can spend time with other family members, who will worry less about the client, but these are not primary reasons for the client to eat.

A client is attending anger management class and wants to know how the class will help. What is the nurse's best response? "It will help you to learn how to control the arousal of anger." "We need to explore what makes you want to hit people when you are angry." "You will learn how to control your violent behavior." "You will be able to stop feeling angry when incidents happen out of your control."

"It will help you to learn how to control the arousal of anger." Explanation: It is unrealistic for someone to stop feeling angry altogether; however, the goal of anger management therapy can help a client learn how to control the arousal of anger. Anger management therapy is not utilized for clients who are violent when angry because it has not been found to be effective in modifying violent behavior.

The nurse is assessing a client's abstract reasoning. Which statement made by the nurse to the client would elicit the most acccurate information regarding this clinical feature? "Can you tell me what you ate for breakfast this morning?" "Are you hearing voices that tell you to do certain things?" "People in glass houses should not throw stones." "Can you tell me what day of the week it is?"

"People in glass houses should not throw stones." Explanation: The nurse assesses the client's ability to use abstract thinking, which is to make associations or interpretations about a situation or comment. The nurse can usually do so by asking the client to interpret a common proverb such as "a stitch in time saves nine." If the client can explain the proverb correctly, their abstract thinking abilities are intact. If the client provides a literal explanation of the proverb and cannot interpret its meaning, abstract thinking abilities are lacking. Asking the client what they ate for breakfast this morning is assessing short-term memory. Hearing voices would assess the presence of hallucinations and altered thought process. The nurse will test for orientation by asking what day of the week it is.

A client is admitted to the psychiatric-mental health unit for panic attacks and suicidal ideations after witnessing a fatal motor vehicle accident. During the initial encounter, what comment made by the nurse would be most therapeutic for the client? "Tell me how you are feeling right now." "I'm sorry this has happened to you." "It's only going to get better from here, hang in there." "You have to put yourself first and start a self-care routine."

"Tell me how you are feeling right now." Explanation: Patience, listening, and empathy are important tools that along with a calm, nurturing approach can help establish trust. The nurse should be careful not to give unrealistic or false reassurances of positive outcomes, because the client may feel worse before getting better in a crisis state. The nurse's comment, "Tell me how you are feeling right now" is a therapeutic approach that is open-ended to allow the client to express their feelings without judgment. The nurse's statements, "It's only going to get better from here, hang in there", and "You have to put yourself first and start a self-care routine" are non-therapeutic comments. T he nurse's comment, "I'm sorry this has happened to you" is sympathetic but does not offer the client the opportunity to speak about their feelings.

Which question would be best for the nurse to ask in order to assess recent memory? "How are an orange and an apple different?" "Why are you at the health care clinic today?" "When is your birthday?" "What did you eat for breakfast today?"

"What did you eat for breakfast today?" Explanation: Recent memory or short-term memory asks the client about things and events that are happening currently. Asking the client what they ate for breakfast is testing recent memory. Asking for the client's birth date tests remote memory. How an orange and an apple are different tests a client's ability for abstract reasoning. If a client can tell the nurse why they are at the clinic, this assesses the client's orientation (location).

Which statement, made by the parent of a teen diagnosed with conduct disorder, demonstrates effective parenting? "You will lose your driving privileges for a week if you don't clean your room today." "A person your age knows better than to skip school." "When are you going to learn that bullying is not acceptable behavior?" "Do you understand that you hurt your sister's feelings when you call her names?"

"You will lose your driving privileges for a week if you don't clean your room today." Explanation: The nurse should help parents identify appropriate discipline strategies. While the other options express appropriate parental emotions, they do not address parenting strategies that will effectively address the teen's behavior

A nurse has been asked to identify children with attention deficit hyperactivity disorder (ADHD) in a school. Which children should the nurse identify as having ADHD? Select all that apply. A child who has limited facial expressions and poor eye contact A child who is not able to dress himself or herself independently A child who makes excessive noise by tapping the desk A child who verbally abuses other children in the class A child who does not follow instructions in class

A child who makes excessive noise by tapping the desk A child who does not follow instructions in class

A client has responded to the recent diagnosis of lung cancer by making extensive plans for overseas travel with the client's children, despite the fact that the oncologist has informed the client of the extremely poor prognosis. The nurse consequently recognizes that the client is likely in the denial stage of grief. How can the nurse best facilitate adaptive grieving for this client? Enlist the assistance of another nurse to help the client face the reality of the situation Address the client's diagnosis and prognosis at a later time or date Restate the client's situation in more specific and detailed terms Supplement conversations with the client by using written material about the diagnosis

Address the client's diagnosis and prognosis at a later time or date Explanation: In the absence of the client's readiness to become more aware of the situation, the nurse should respect the client's current position and revisit the matter when the client is more ready. It is disrespectful, and likely counterproductive, to have others reiterate the message, to provide written material, or to increase the amount of detail if the client is not ready to engage at this time

A psychiatric-mental health nurse is searching for a nursing organization that shapes mental health policy. Which nursing organization helps create mental health policy and improves mental health care for culturally diverse clients and communities? International Society of Psychiatric Nursing (ISPN) American Nurses Association (ANA) American Psychiatric Nurses Association (APNA) International Society of Psychiatric Consultation Liaison Nurses

American Psychiatric Nurses Association (APNA) Explanation: The American Psychiatric Nurses Association (APNA) is the largest psychiatric-mental health (PMH) nursing organization, and the organization works to advance PMH nursing practice and helps shape mental health policy to improve mental health care for culturally diverse clients and communities. The International Society of Psychiatric Nursing (ISPN) focuses on specific interests of PMH nursing and consists of four divisions including the Association of Child and Adolescent Psychiatric Nurses, International Society of Psychiatric Consultation Liaison Nurses, Society for Education and Research in Psychiatric-Mental Health Nursing, and Adult and Geropsychiatric-Mental Health Nurses. The American Nurses Association (ANA) fosters high standards of practice, promotes safe and ethical work environments for nurses, and advocates for needed health care policy and legislation.

After receiving word from the oncologist that the client's tumor is malignant, the client says to the nurse, "If you people had the faintest clue what you were doing, I wouldn't be like this." The nurse should recognize that the client may be experiencing which stage of grief? Denial Depression Anger Bargaining

Anger Explanation: The client's hostile statement indicates that the client may be in the anger stage of grief, during which an individual may become difficult or demanding.

A client has just been diagnosed with terminal brain cancer and given approximately 2 months to live. The client wishes to visit the client's mother soon to "say goodbye." The nurse acknowledges this reaction as what? Bereavement Mourning Anticipatory Loss

Anticipatory Explanation: Anticipatory grief refers to the reactions that occur when an individual, family, significant other, or friends are expecting a loss or death to occur. Bereavement is the process of grief that includes feelings of sadness, insomnia, poor appetite, deprivation, and desolation. Mourning describes an individual's outward expression of grief regarding the loss of a loved object or person. Loss is a change in the status of a significant object or situation.

A client is diagnosed with terminal kidney failure. The client's spouse demonstrates loss and grief behaviors. Which term accurately describes the spouse's experience? Anticipatory grief Dysfunctional grieving Bereavement Maturational loss

Anticipatory grief Explanation: Anticipatory loss occurs when a person displays loss and grief behaviors for a loss that has yet to take place. It is often seen in the families of clients with serious or life-threatening illnesses and serves to lessen the effect of the actual loss of a family member.

Children with conduct disorder may be diagnosed with which disorder as adults? Depression Antisocial personality disorder Schizophrenia Bipolar disorder

Antisocial personality disorder Explanation: As many as 30% to 50% of children diagnosed with conduct disorder are diagnosed with antisocial personality disorder as adults.

The nurse is conducting an admission interview with a psychiatric-mental health client. The nurse uses observational skills to identify that the client has a flat affect. The nurse is engaging in which part of the nursing process? Assessment Planning Diagnosis Evaluation

Assessment Explanation: Assessment is the step of the nursing process in which data are collected and analyzed. Observations of the client's mood and affect are part of this step. The other steps of the nursing process are diagnosis, planning, implementation, and evaluation.

A nurse is providing community education regarding adolescents with oppositional defiance disorder (ODD). Which point should the nurse include in the educational session? Parental roles do not influence the development of ODD. Rewarding positive behaviors consistently can lead to ODD. Behavior problems can develop when parental figures pay attention to a child's maladaptive behaviors. It is ideal if parents can wait until adolescence to seek treatment.

Behavior problems can develop when parental figures pay attention to a child's maladaptive behaviors. Explanation: The disruptive, defiant behaviors associated with ODD usually begin at home with parents or parental figures and are more intense in this setting than in settings outside the home. Consistently giving attention to maladaptive behaviors and ignoring any positive ones can lead to the development of ODD. With ODD, the problem develops as a result of the parents or parental figures to miss opportunities to reward the child for demonstrating positive behaviors but attention, whether it is positive or negative, is typically given when the child is engaging in maladaptive behavior. Parents/parental figures play a key role in preventing or perpetuating ODD. The problem behaviors are learned and inadvertently reinforced in the home. The most effective treatment for ODD begins when the child is young, preferably elementary school-aged. Waiting until adolescence to seek treatment can render the client more treatment resistant

A client with persistent depression is considering electroconvulsive therapy (ECT). The nurse has seen ECT be effective in other cases. When the client expresses fear and doubt about undergoing ECT, the nurse tries to talk the client into it, because the nurse truly believes it will help the client. Which two ethical concepts are in conflict? Beneficence and autonomy Beneficence and fidelity Justice and autonomy Fidelity and paternalism

Beneficence and autonomy Explanation: Beneficence and autonomy are in conflict. Beneficence is practicing with the intent to do good; however, professionals define how to do good, which may override the wishes and self-determination of the client. Autonomy is the client's right to make decisions for himself or herself. Justice refers to fairness; that is, treating all people fairly and equally without regard for social and economic status, race, sex, marital status, religion, ethnicity and cultural beliefs. Fidelity is the nurse's faithfulness to duties, obligations, and promises.

The nurse interacts with a client who states "I am so angry and frustrated. I was supposed to be able to go home today and now they are saying I have to stay another day." Which principle should guide the nurse's response? Clients who can verbalize angry feelings are less likely to display hostile behaviors. The client is in the escalation phase and a show of force should be implemented. Verbalization of feelings associated with anger usually precedes acting out. Using physical outlets for expressing anger is the most effective strategy.

Clients who can verbalize angry feelings are less likely to display hostile behaviors. Explanation: Clients who have developed the ability to verbalize feelings, especially those associated with anger, are less likely to display hostile behaviors. Verbalization of feelings does not usually precede acting out behaviors, which are generally related to poor impulse control. The escalation phase is associated with behaviors that indicate movement toward a loss of control rather than an increase in control, as shown by the ability to verbalize feelings of frustration. Recommending aggressive techniques while the client is experiencing anger is likely to worsen tension rather than relieve it

The spouse of a client who died of breast cancer is still grieving 2 years later. What type of grief is the spouse experiencing? Inhibited Situational Complicated Maturational

Complicated Explanation: Unresolved grief is abnormal or distorted; it may be either unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them; unresolved grief also describes a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations

A 16-year-old client is highly disruptive in class and has been in trouble at home. The client's parent recently found the client torturing a cat. When the parent questioned the client about how the client could hurt an animal, the client laughed. Which condition will the client most likely be diagnosed with? Bipolar disorder Conduct disorder Asperger syndrome Tourette syndrome

Conduct disorder Explanation: Adolescents with conduct disorder are often unmanageable at home and disruptive in the community. They have little empathy or concern for others. They may be callous and lack appropriate feelings of guilt, although they may express remorse superficially to avoid punishment. They often blame others for their actions. Risk-taking behaviors such as drinking, smoking, using illegal substances, experimenting with sex, and participating in crime are typical. Cruelty to animals or people, destruction of property, theft, and serious violations of rules are diagnostic criteria.

The nurse is planning the environment for a newly-admitted client with a history of violence toward others. Which modification would the nurse implement? Confirm that the utility and storage rooms are kept locked. Place the client in a semi-private room with another client. Ensure the client is at the end of the hall away from the nurse's station. Provide the client metal hangers instead of plastic hangers in closet

Confirm that the utility and storage rooms are kept locked. Explanation: As part of keeping the environment safe with clients who are potentially violent, the nurse should keep storage and utility rooms locked to decrease access to items that may be used for self-harm or harm to others. The client should be in a single room, and not a semi-private room with another client. The client should be near the nurse's station, and have plastic, not metal, hangers with the clothes closet due to the risk for injury to self or others

A nurse working with an adolescent client diagnosed with disruptive behavior disorder is developing a plan of care to improve outcomes. Which nursing action best supports the use of problem-solving therapy? Consider alternative approaches based on their individual merits. Focus on the written understanding of words and their meanings. Provide the client with a checklist for comparison of decisions. Tell the client that one should wait 24 hours before making any choice.

Consider alternative approaches based on their individual merits.

The nurse is caring for a client who has just been diagnosed with cancer. The client states that the client will "never be able to cope with this situation." What is the nurse aware that coping is? Coping is a physiologic measure used to deal with change, and the client will physically adapt. Coping is the physiologic and psychological processes that people use to adapt to change. Coping is the human need for faith and hope, which create change. Coping is a social measure used to deal with change and loss.

Coping is the physiologic and psychological processes that people use to adapt to change. Explanation: Indicators of stress and the stress response include both subjective and objective measures. They are psychological, physiologic, or behavioral and reflect social behaviors and thought processes. The physiologic and psychological processes that people use to adapt to stress are the essence of the coping process. Coping is both a physiologic and psychological process, is a process used to adapt to change, and is a personal process used to adapt to change

Which statement about culture is true?

Cultural identity reflects what determines behavior.

A psychiatric-mental health nurse is providing care to a client who has recently immigrated to the United States. Which action(s) would be appropriate to provide effective culturally competent care? Select all that apply. Structure the interaction based on facility's protocol. Demonstrate a genuine interest in the client. Acquire information about the client's country. Learn a few key words in the native language. Avoid assumptions about the client's culture.

Demonstrate a genuine interest in the client. Avoid assumptions about the client's culture. Acquire information about the client's country.

The nurse is assessing a client who is recently divorced. The client tells the nurse that the memories of the client's former spouse are interfering with an ability to concentrate at work. According to Horowitz's stages of loss and adaptation, this is indicative of which stage? Working through Completion Denial and intrusion Outcry

Denial and intrusion Explanation: According to Horowitz's stages of loss and adaptation, in the stage of denial and intrusion, the client at times becomes so intensely preoccupied with the memories of the loss that they intrude into every moment and activity of the client's day. In the stage of outcry, the client realizes the loss for the first time. Outcry could be expressed outwardly or suppressed internally. Completion is the stage where the client becomes normal and the memories of the loss do not intrude in the day-to-day life any longer. In working through this stage, the client does think about the loss but also tries to find ways to manage with the loss

A nurse is beginning the process of providing therapy to a client with anger management problems. When implementing this therapy, which should occur first to promote optimal effectiveness? Client self-monitoring for anger cues Avoidance of stimuli that provoke the anger Identification of measures to disrupt the anger response Development of a therapeutic relationship

Development of a therapeutic relationship Explanation: With cognitive-behavioral therapy, the recommendation is to first establish the therapeutic alliance because some angry individuals are not in a stage of readiness to change their behavior. When clients are more receptive, cognitive-behavioral therapy involves avoidance of provoking stimuli, self-monitoring regarding cues of anger arousal, stimulus control, response disruption, and guided practice of more effective anger behaviors.

Which is a term used to describe grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported socially? Disenfranchised grief Mourning Anticipatory grieving Bereavement

Disenfranchised grief Explanation: Disenfranchised grief is grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported socially. Anticipatory grieving is when people facing imminent loss begin to grapple with the very real possibility of the loss or death in the near future. Bereavement refers to the process by which a person experiences the grief. Mourning is the outward expression of grief.

In order to help preserve and maintain a client's cultural belief regarding the need for "hot foods," which action should the culturally competent nurse take? Educate the staff to help them assist the client in selecting food choices from the client's menu that supports this belief Ask for a dietary consult with an understanding of the "hot and cold food" belief Discuss the possibility of the family providing the appropriate foods Assure the client that these needs will be considered by the staff

Educate the staff to help them assist the client in selecting food choices from the client's menu that supports this belief Explanation: In cultural care preservation/maintenance, the nurse assists the client in maintaining health practices that are derived from membership in a certain ethnic group. The nurse helps the client select and obtain foods congruent with these beliefs most effectively by educating staff. This is not necessarily possible or even advised if there are medically required food restrictions.

Personal space and distance is a cultural perspective that can impact nurse-client interactions. What is the best way for the nurse to interact physically with a client who has a different cultural perspective on space and distance than the client? Explain that physical contact is necessary and ask about the client's cultural personal space preferences. Realize that sitting close to the client is an indication of warmth and caring. Sit 3 to 6 feet away from the client in an attempt to not offend. Remember not to intrude into the personal space of the elderly.

Explain that physical contact is necessary and ask about the client's cultural personal space preferences. Explanation: When providing nursing care that involves physical contact, the nurse should know the client's cultural personal space preferences. Sitting close or too far away from the patient may be interpreted as offensive. Age is not necessarily a deciding factor in regard to a person's cultural practices.

An agitated client has been put in restraints against the client's will because of inadequate staffing. The nurse determines this as which form of malpractice? Defamation Assault False imprisonment Battery

False imprisonment

An agitated client has been put in restraints against the client's will because of inadequate staffing. The nurse determines this as which form of malpractice? Battery False imprisonment Defamation Assault

False imprisonment Explanation: False imprisonment is the intentional and unjustifiable detention of a person against his or her will. Detention can occur with the use of physical restraint, barriers, or threats of harm. Battery is unlawful touching of another without consent. Defamation involves injury to a person's reputation or character through oral (slander) or written (libel) communications to a third party. Assault is an act that puts another person in apprehension of being touched or of bodily harm without consent.

An agitated client has been put in restraints against the client's will because of inadequate staffing. The nurse determines this as which form of malpractice? False imprisonment Battery Defamation Assault

False imprisonment False imprisonment is the intentional and unjustifiable detention of a person against his or her will. Detention can occur with the use of physical restraint, barriers, or threats of harm. Battery is unlawful touching of another without consent. Defamation involves injury to a person's reputation or character through oral (slander) or written (libel) communications to a third party. Assault is an act that puts another person in apprehension of being touched or of bodily harm without consent.

A client comes to the emergency department with severe depression and suicidal ideation. Staff members determine that the client does not have adequate insurance to cover inpatient psychiatric services at their facility, so they discharge the client with some prescriptions for medication. Which principle is being ignored by discharging this client? None of the above Justice Veracity Autonomy

Justice Explanation: Justice is the duty to treat all clients fairly. It can become an ethical issue in mental health when a segment of the population does not have access to care, as in this case, in which access to inpatient care is warranted but denied.

A client is being seen in the clinic after a natural disaster. The client is crying but believes that their social support is adequate. What is the appropriate nursing action to support the client? Refer the client to a mental health specialist. Provide counseling and support during the visit. Assess the client's nutritional status. Admit the client to the hospital.

Provide counseling and support during the visit. Explanation: The client is having psychological distress, which is to be expected after a disaster situation. The client believes that their support network is adequate, which would positively assist the client with coping with the distressing emotions. At this time, the nursing action should be to provide counseling and support during the visit. Referring the client to a mental health specialist or admitting the client to the hospital would be more restrictive than necessary for the client's status. Assessing the client's nutritional status would be indicated if the client appeared emaciated or reported weight changes.

The nurse is caring for a client who has recently developed psychomotor retardation. Based on this information, which behavior would the nurse expect to see in this client? Slowness of body movements Speaking meaningless words Repeated tapping of the foot Maintenance of an awkward posture for a long time

Slowness of body movements Explanation: Slowing of thought processes and bodily movements is referred to as psychomotor retardation. Repeated tapping of foot is referred to as automatism which is often caused due to anxiety. Speaking words that are only meaningful to the client and nobody else is referred to as neologisms. Maintenance of an awkward posture for a long time is an abnormal behavior and is referred to as waxy flexibility.

A nurse is assessing a client who is depressed but unwilling to discuss the client's feelings. After speaking with the client's caregiver, the nurse learns that the client's pet died recently. Which is the most likely reason the client has hesitated to express the client's feelings? The client does not want to remember the memories of the pet. The client feels that the feelings related to the pet's death are insignificant. The client feels that the nurse would not consider the grief as significant. The client feels that the nurse would not be able to make the client feel better. hesitated: pause before saying or doing something, especially through uncertainty.

The client feels that the nurse would not consider the grief as significant. Explanation: A loss, such as the death of a pet, may not be considered socially significant and, therefore, the accompanying grief would not be legitimized. The client feels that the nurse would not consider the grief as significant and would not take it seriously. This is reflective of disenfranchised grief. It is not likely that the client is trying to avoid the thoughts related to the loss. The client is less likely to feel that the nurse would not be able to help.

The nurse is assessing a client who is deeply upset and is not expressing feelings. At the end of the assessment, the nurse concludes that the client is extremely depressed because of the death of a loved one. The client has disenfranchised grief. What is the most likely reason for the client not being willing to speak about it to the nurse? The client does not yet feel ready to talk about the feelings. The client feels uncomfortable speaking about the relationship with the deceased. The client wants to forget about the person who is dead. The client feels that the nurse would not be able to make the client feel better.

The client feels uncomfortable speaking about the relationship with the deceased. Explanation: Disenfranchised grief is the grief over a loss that cannot be acknowledged openly or publicly or is considered socially unacceptable. These include the loss of loved one in secret or closeted same-sex relationships, cohabitation without marriage, and extramarital affairs. The stigma associated with the relationship of the client and the deceased would not allow the client to comfortably express his or her feelings about the relationship to the nurse. The need to forget about the deceased, feeling of not being ready to talk to the nurse, and believing that the nurse will not be able to make the client feel better are less likely reasons for the client to not express feelings.

A nurse is assessing a Korean client. The caregiver of the client tells the nurse that the client had been diagnosed with Hwa-Byung by their local health care provider. What should the nurse interpret from this? The client had intermittent episodes of anger outbursts. The client had somatization disorder. The client had paranoid delusions and hallucinations. The client had health-related issues due to suppression of anger.

The client had health-related issues due to suppression of anger. Explanation: Hwa-Byung, or fire illness, is a culture-bound syndrome in Korea where a client has symptoms such as abdominal pain and insomnia as a result of suppression of anger. A nurse who is aware of the culture bound syndromes would understand that the client's health-related complaints are due to suppression of anger. Somatization is an incorrect diagnosis for this condition, often given by Western practitioners unaware of Hwa-Byung. Paranoid delusions and hallucinations are not seen in this culture-bound syndrome. This condition is not known to include intermittent episodes of anger outbursts

A client's roommate yells at the client and the client acts as if nothing has occurred and ignores the roommate. The nurse identifies that the client may have which style of anger expression related to this incident? expressive anger anger suppression catharsis of anger constructive anger discussion

The client is not expressing anger based on the incident and therefore has anger suppression which means the client is internalizing this emotion.

The nurse is planning education for a client who has exhibited aggression on techniques to manage anger. Which situation would be best for providing this education? The client is having an argument with a roommate. The client is sitting in the dayroom reading a book. The client is having lunch with family members. The client is threatening to hit another client.

The client is sitting in the dayroom reading a book. Explanation: When the client is reading a book, the client may be amenable to the nurse's opening communication about managing anger. The optimal time to provide education for a client on techniques to manage anger and aggression is not when anger and violence are being exhibited. In those cases, the priority is to deescalate the situation and ensure the safety of everyone involved. Therefore, when the client is having an argument or threatening to hit someone else, that is not the best time to provide teaching. It is possible that the client will be receptive to teaching after an incident has resolved, when they may coached to reflect on the outcomes of their behavior and how things could have gone better. Eating lunch with family members is a social situation, and the client should not be interrupted for education until through socializing.

A 22-year-old client has voluntarily sought treatment for an eating disorder at a rural residential facility. Despite a promising start, the client has been involved in recent conflicts with staff members and insists that the client wants to leave the facility. Staff members have refused to facilitate the client's transportation from the facility and have stated that they will not return the client's money and identification that were held when the client was admitted. Staff at the treatment facility may be guilty of false imprisonment due to what? The client voluntarily admitted for treatment. The facility is in an inaccessible location. The client's diagnosis is not terminal. The client's diagnosis is not psychiatric in etiology.

The client voluntarily admitted for treatment. Explanation: False imprisonment is the intentional and unjustifiable detention of a person against his or her will. The client voluntarily sought treatment and is not a physical threat to the self or others. The client's prognosis and the location of facility are not among the criteria for false imprisonment. Eating disorders are psychiatric illnesses.

The nurse has been working with the client to develop impulse control over the previous 3 days. Which assessment finding supports that the plan of care was successful? The client waits patiently in line for medications. The client comes to tell the nurse that they are frustrated because group was canceled. The client walks away from another client who insulted them. The client appears caring and attentive during visiting hours with the spouse.

The client walks away from another client who insulted them. Explanation: Impulse control is the ability to delay gratification. Aggressive behavior is seen as a means of reestablishing control, improving mood, or achieving retribution, all of which fail to achieve those ends. The ability of the client to be patient in line or attentive to their spouse does not directly relate to impulse control of expressing feelings of anger when they occur. When the client felt anger at another client for insulting them, they demonstrated the ability to delay the gratification of acting aggressively to the client. Expressing frustration is an expected outcome of anger management treatment related to developing the ability to express anger in words rather than physical actions.

A nurse is developing a plan of care for a client with conduct disorder. Which would be treatment outcomes for this client? Select all that apply. The client will engage in socially acceptable behavior. The client will have a hygienic lifestyle. The client will not hurt others or damage property. The client will be relieved of anxiety and depression. The client will learn effective problem-solving skills.

The client will engage in socially acceptable behavior. The client will learn effective problem-solving skills. The client will not hurt others or damage property. f a client undergoes successful treatment, he or she should be able to behave in a socially acceptable manner, display appropriate problem-solving skills, and no longer hurt others or damage property. Clients with conduct disorder usually do not have issues related to personal hygiene. Such clients do require relief from anxiety or depression, as they are considered unemotional and do not show regret or feel any remorse after inappropriate behavior.

An adult client is grieving the loss of a parent while being evaluated for another unrelated problem. The client has had a previous psychiatric diagnosis and displays mistrust toward others. Which outcome should be identified for the client? The client will maintain functional ability in all areas of life while grieving. The client will engage in social activities within 1 week. The client will seek or accept professional assistance, if needed, to promote the grieving process. The client will anticipate the grieving process to be 1 year long.

The client will seek or accept professional assistance, if needed, to promote the grieving process. Explanation: The grieving process varies from person to person and can be complicated by many different barriers. The client in the scenario has experienced the death of a parent, which is a major loss. In addition, the client has had a previous psychiatric diagnosis and does not trust other people, which are two aspects that predispose the client to complicated grieving. Therefore, the outcome for the client should be identified as "The client will seek or accept professional assistance, if needed, to promote the grieving process." The outcomes, "The client will anticipate the grieving process to be 1 year long", "The client will maintain functional ability in all areas of life while grieving", and "The client will engage in social activities within 1 week" are unrealistic and unattainable at this time.

A nurse is assessing an adolescent who is constantly bullying other children. Which findings during the assessment are suggestive of early onset conduct disorder? Select all that apply. The maladaptive behavior started before the age of 10 years. No extremely aggressive behavior is observed. Client never abused other children physically. Client is susceptible to developing schizoid personality disorder. Client does not have normal peer relationships.

The maladaptive behavior started before the age of 10 years. Client does not have normal peer relationships. n early onset conduct disorder, the aggressive behavior begins before the age of 10 years. Unlike individuals with the adolescent-onset type, this client does not have normal peer relationships. In early onset conduct disorder, the behavior of the child is extremely aggressive. Information regarding the susceptibility of the child to develop antisocial personality disorder cannot be obtained during assessment. Severity of maladaptive behavior is not indicative of the type of conduct disorder (on the basis of age). The client may have a history of being abusive to children.

A client with a psychiatric illness has become extremely aggressive and the nurse decides that the client needs to be restrained. Which action would be considered human restraint? The nurse ties the client's wrist using wrist restraints. The nurse asks the client to calm down. The nurse and a group of paramedics hold the client. The nurse sedates the client with morphine.

The nurse and a group of paramedics hold the client. Explanation: Restraint is the direct application of physical force to restrict the client's freedom of movement. The nurse and a group of paramedics holding the client is an example of human restraint. The nurse does not apply force while telling the client to calm down. Sedating the client is an example of chemical restraint. Applying a wrist cuff to control the aggression of the client indicates the use of mechanical restraints.

A nurse is conducting a mental status examination on a client diagnosed with severe depression. The nurse asks the client to repeat the days of the week backward. What component of the examination is the nurse assessing in the client? abstract thinking sensory-perception alterations memory ability to concentrate

ability to concentrate Explanation: The nurse asking the client to repeat the days of the week backward is assessing the client's ability to concentrate. Abstract thinking can be assessed by asking the client to interpret a common proverb or analogy. Sensory-perceptual alterations can be assessed by assessing for the presence of hallucinations. Memory can be assessed by asking the client to recall their previous day's activities or asking for the client to recall the state's capital

A client who is involuntarily admitted to the psychiatric facility refuses to take a psychotropic medication. The nurse holds the client down to give the medication. Which statement is true regarding this situation? The client cannot refuse the medication. The nurse is protected under the Nurse Practice Act. The client is unable to make competent decisions. The nurse may be held legally liable.

The nurse may be held legally liable. Explanation: Just because a person is involuntarily admitted for mental health treatment does not mean that person loses their rights. This client has the right to refuse treatment and the nurse may be held legally liable for infringing on those rights. The remaining answer choices are incorrect

A nurse is assessing an adolescent with conduct disorder. Which statement by the nurse about the adolescent is most likely to be true? The client has a chronic medical condition. The sibling of the client has conduct disorder. The adolescent loves to play with pets. The sibling of the client has a mood disorder.

The sibling of the client has conduct disorder. Explanation: Most children with conduct disorder have siblings with the same psychiatric disorder. Although it is possible to develop conduct disorder if a sibling has a mood disorder, the likelihood is higher that the client would also develop a mood disorder. Clients with conduct disorder will show cruelty to animals. A client with a chronic medical condition is more likely to be able to experience and convey empathy, eliminating the presence of conduct disorder.

A nurse is caring for a Jewish client with a terminal illness who is on a ventilator. The spouse of the client intends to stay near the client when the ventilator is removed. What is the reason for such a request, according to the Jewish culture? Choose the best answer. The soul of the deceased should comfortably be able to travel into the afterlife. The soul of the deceased should not be alone while leaving the body. The soul of the deceased should pass through the body of a close family member. The soul of the deceased should not be disturbed by the other spirits.

The soul of the deceased should not be alone while leaving the body. Explanation: The Orthodox Jewish people believe that the soul should not leave the body while the person is alone. Thus a close relative is supposed to be there with a person who is dying. The purpose of this custom is not to prevent disturbance from the other spirits, to help the soul travel comfortably to the afterlife, or to make the soul of the deceased pass through the body of a close family member.

A nurse is considering using restraint and seclusion for a client who is acting out. Which is the primary guideline for the use of restraint and seclusion? Use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent. Use should be limited to emergency situations in which the client is demonstrating a potential to be violent. Use should be limited to times when a client has demonstrated violence and has inflicted harm to self or others. Use should be limited to times when medications have been unsuccessful in de-escalating a situation. SUBMIT ANSWER Exit quiz

Use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent. Explanation: Because of the risks of restraint and seclusion, a primary guideline is that use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent. Furthermore, restraint and seclusion should be applied only when other less restrictive methods to ensure client safety have failed. Nonphysical interventions are the first choice.

A client has come to the mental health center for an initial visit. The nurse has little experience with the client's culture, having cared for only one other client with a similar background. When assessing the new client, which approaches would be best for the nurse to use to provide culturally competent care? Select all that apply. Speak to the client in an informal manner because that is the tone the previous client preferred. Demonstrate genuine interest in learning about the new client. Use the new client as the primary source of information. Ask the new client about personal beliefs and practices. Assume the new client follows beliefs similar to those of the previous client.

Use the new client as the primary source of information. Demonstrate genuine interest in learning about the new client. Ask the new client about personal beliefs and practices.

Which statement would indicate that medication teaching for the parents of a 6-year-old child with attention deficit hyperactivity disorder (ADHD) has been effective? "We're so glad that methylphenidate will eliminate the problems of ADHD." "We'll be sure the child takes methylphenidate at the same time every day, just before bedtime." "We'll be sure to record the child's weight on a weekly basis." "We'll teach the child the proper way to take the medication, so the child can manage it independently

We'll be sure to record the child's weight on a weekly basis." Explanation: Stimulant medications used to treat ADHD can suppress appetite, and the child may lose or fail to gain weight properly. The client is too young to manage medications independently. Ritalin should be given in divided doses, and taking it at bedtime can cause insomnia. Ritalin reduces hyperactivity, impulsivity, and mood lability and helps the child to pay attention more appropriately. However, it does not wholly eliminate the challenges of the disorder.

A psychiatric-mental health nurse is assessing a group of clients. Which client would be at the highest risk for violence towards others? a client diagnosed with schizophrenia who is isolating in their room a client diagnosed with depression experiencing anorexia a client with chronic psychosomatic concerns a client having paranoid delusions that others are out to get them

a client having paranoid delusions that others are out to get them Explanation: Although most clients with psychiatric disorders are not aggressive, clients with a variety of psychiatric diagnoses can exhibit angry, hostile, and aggressive behavior. Clients with paranoid delusions may believe others are out to get them may believe that they are protecting themselves, they retaliate with hostility or aggression. Some clients have auditory hallucinations and may have voices that command them to hurt others. Aggressive behavior is also seen in clients with dementia, delirium, head injuries, intoxication with alcohol or other drugs, and antisocial and borderline personality disorders. Violent clients tend to be more symptomatic, have poorer functioning, and show a marked lack of insight compared with nonviolent clients. The client diagnosed with depression experiencing anorexia, the client with chronic psychosomatic complaints, and the client diagnosed with schizophrenia who is isolating in their room do not pose an imminent danger to others. However, the client having paranoid delusions believing that others are out to get them may become violent; therefore, that client would be at the highest risk for violence toward others.

A nurse is counseling a client with depression on what to do in case the client has suicidal thoughts. Which option may provide the most immediate help for the client? a telephone hotline an outpatient clinic an office visit an emergency clinic

a telephone hotline Explanation: A telephone hotline is an immediate solution for a client to speak with to help with mental health services if having thoughts of suicide. The client would then want to transport to an emergency clinic for face-to-face evaluation and treatment. An outpatient clinic or office visit would not provide emergency treatment for a client who is suicidal.

The nurse is caring for a client who was born and educated in southeast Asia. The client moved to the United States two years ago. The client wears Western clothing and eats fast food. Which answer describes what the client has modeled? acculturation ethnic mosaic cross culturalism inclusiveness

acculturation Explanation: Acculturation is the term used to describe the socialization process by which minority groups learn and adopt selective aspects of the dominant culture. - Ethnic mosaic/ .--a mix of different ethnic groups, languages, and cultures. - cross culturalism (Đa văn hóa) :is distinct from multiculturalism, dealing with or offering comparison between two or more different cultures or cultural areas - inclusiveness : the quality of covering or dealing with a range of subjects or areas.

The nurse is caring for a client who was born and educated in southeast Asia. The client moved to the United States two years ago. The client wears Western clothing and eats fast food. Which answer describes what the client has modeled? ethnic mosaic inclusiveness acculturation cross culturalism

acculturation Explanation: Acculturation is the term used to describe the socialization process by which minority groups learn and adopt selective aspects of the dominant culture.

Which factor has the greatest impact on a person's ability to cope with illness? occupation gender age financial status

age Explanation: A person's age seems to affect how he or she copes with illness. For instance, the age at onset of schizophrenia is a strong predictor of the prognosis of the disease. People with a younger age at onset have poorer outcomes, such as more negative signs (apathy, social isolation, and lack of volition) and less effective coping skills, than do people with a later age at onset. While the other options may exert some impact, the degree is not as profound as the affect of age.

A client with depression tells the nurse, "I want to stop taking my antidepressant medication because I don't like taking medications." The nurse discusses the benefits of adhering to the medication plan and strongly urges the client to use the medication. The nurse interprets the client's statement as reflecting which ethical principle? beneficence paternalism justice autonomy

autonomy Explanation: Autonomy reflects the fundamental right of all persons for self-determination, to make independently make choices. Autonomy is reflected by the client's statement to stop taking the medication. The nurse's urging the client to continue to use the medication because of the medication's benefits reflects the principle of beneficence, that is, the nurse is using scientific knowledge and incorporating that knowledge to promote the client's maximum health potential. In this case, the medication would help to control the client's depressive symptoms. Justice reflects the duty to treat all fairly; paternalism is the belief that knowledge and education authorize professionals to make decisions for the good of the client.

A nurse is working in a psychiatric-mental health facility. The nurse observes a client pacing and punching the wall. Which measure can the nurse take for personal safety? Stand on the client's dominant side. Avoid standing close to a door. Stand with hands behind the back. Avoid being alone with the client.

avoid being alone with the client. Explanation: If a nurse gets into a "situation": take a position just outside the client's personal space (slightly out of arm's reach); if possible, stand on the client's nondominant side (usually the side on which he or she wears a wristwatch); keep an open posture with hands in sight; keep the client in visual range; and make sure the door of a room is readily accessible. Avoid letting the client get between the nurse and the door, be friendly and concerned, and avoid being demanding unless the danger is imminent. If the latter occurs, it is perfectly acceptable to say "please stop that now" authoritatively. Retreat from the situation and summon help if the client's aggression escalates to imminent violence, and avoid being alone with an escalating clien

The nurse is teaching a client about the importance of adhering to a medication regimen. The client does not believe that it is important. The nurse is communicating which ethical principle? justice veracity paternalism beneficence

beneficence Explanation: According to the principle of beneficence, the health care provider uses knowledge of science and incorporates the art of caring to develop an environment in which individuals achieve their maximum health care potential. Justice is the duty to treat all fairly, distributing the risk and benefits equally. Veracity is the duty to tell the truth. Paternalism is the belief that knowledge and education authorize professionals to make decisions for the good of the client.

Providing milieu therapy is an example of the use of which ethical principle? fidelity beneficence veracity autonomy

beneficence Explanation: When using the ethical principle of beneficence, a health care provider uses knowledge of science and incorporates the art of caring to develop an environment in which individuals achieve their maximal health care potential, as in milieu therapy. Veracity is the duty to tell the truth. Fidelity is faithfulness to obligations and duties. According to the principle of autonomy, each person has the fundamental right of self-determination.

A psychiatric-mental health nurse is conducting an initial interview with a client admitted for hallucinations and abdominal pain. The client is focused on the pain and cannot concentrate on the assessment questions being asked. What is the initial desired outcome of the client? client understood the importance of the assessment client's pain level decreased assessment completed client's anxiety level decreased

client's pain level decreased Explanation: The client's health status can affect the psychosocial assessment. If the client is anxious, tired, or in pain, the nurse may have difficulty eliciting the client's full participation in the assessment. The nurse needs to recognize these situations and deal with them before continuing the full assessment. The client may need to rest, receive medications to alleviate pain, or be calmed before the assessment can continue. The client in the scenario is reporting pain; therefore, the initial outcome would be that the client's pain level is decreased. There is no indication that the client is experiencing anxiety; therefore, having the client's anxiety level decrease is not applicable. The outcomes of completing the assessment and the client's understanding of the importance of the assessment can occur after their pain is decreased.

Which type of grief occurs when a person is stuck in a state of chronic grieving? uncomplicated grief traumatic grief bereavement complicated grief

complicated grief Explanation: During complicated grief, the person is frozen or stuck in a state of chronic mourning. Most bereaved people experience normal or uncomplicated grief after the loss of a loved one. Traumatic grief is a more difficult and prolonged grief in which external factors influence the reactions and potential long-term outcomes. Bereavement is the process of mourning and coping with the loss of a loved one.

After working with a client who has a history of violent behavior to identify possible clues that suggest the behavior is escalating, a nurse and the client develop a plan for prevention. Which strategies will the nurse be most likely to include? Select all that apply. counting to 10 watch action movies playing loud music taking slow, deep breaths taking a voluntary time out

counting to 10 taking slow, deep breaths taking a voluntary time out

The nurse educator is discussing spirituality for nurses in a mental health class. The nurse educator asks a student nurse, "Which of the following is MOST consistent with spirituality?" The student nurse identifies which description? closely intertwined with beliefs about health and mental illness feeling a connection to a higher power living according to one's beliefs participation in common ways of worshiping

feeling a connection to a higher power Explanation: Spirituality develops over time and is a dynamic, conscious process characterized by two movements of transcendence; either deep within the self or beyond the self. - Self-transcendence involves self-reflection and living according to one's values in establishing meaning to events and a purpose to life. - Closely intertwined with beliefs about health and mental illness, living according to one's beliefs, and participation in common ways of worshipping are not things that are most consistent with spirituality.

A 15-year-old client with intermittent explosive disorder (IED) gives no history of childhood abuse, neglect, or maltreatment. What could be the cause of the disorder in this client? Dysfunction of the parietal lobe Imbalance in the production of serotonin Presence of coronary artery disease Depleted levels of glucose in the blood

mbalance in the production of serotonin Explanation: Childhood abuse, neglect, or maltreatment is often the cause of IED. As the client does not have a history of any of these, the client likely has the disorder because of other factors. Other etiologic factors include imbalance in the production of serotonin and dysfunction of the frontal lobe. Parietal lobe dysfunction and depleted blood glucose levels are not associated with IED. Presence of coronary artery disease is not a known etiologic factor in IED but is strongly correlated with the disease.

The nurse observes a group of individuals who have experienced the traumatic loss of their homes and personal belongings due to a natural disaster. The nurse anticipates which of the following clients may be at highest risk for the development of complicated grieving? middle-aged adult renting an apartment with their best friend adolescent whose parents were traveling out of state young adult living alone in a single-family home older adult who had lived in the home their entire life

older adult who had lived in the home their entire life Explanation: People who are vulnerable to complicated grieving include those with the following characteristics: low self-esteem, low trust in others, a previous psychiatric disorder, previous suicide threats or attempts, absent or unhelpful family members, and persons with insecure or especially strong attachment to the lost person, place, or thing. Although grief is highly individualized, the person at highest risk is the older adult who has never lived in another residence. The other options are less likely to have as secure attachment to a physical home.

A hospitalized client diagnosed with panic attacks is being assessed by the nurse on shift. Upon assessment, the client states their name correctly and that they are in the hospital. The client believes the year is 5 years ago and that they are hospitalized because their pet died. How would the nurse document the client's orientation status? oriented X 4 oriented X 3 oriented X 2 oriented X 1

oriented X 2 Explanation: Orientation refers to the client's recognition of person, place, time, and situation. If the client can recall all four of these details accurately, the client's orientation status is documented as oriented X 4, because each category is documented as a point. The client in the scenario knows who they are (person) and that they are in the hospital (place). The client does not know the current year (time) or why the client is in the hospital (situation). Therefore, the nurse would document the assessment findings as oriented X 2. Oriented X 1 would indicate that the client is oriented to person only. Oriented X 3 would indicate that the client is oriented to a combination of three orientation components. Oriented X 4 would indicate that the client is fully oriented to person, place, time, and situation.

A psychiatric-mental health nurse is conducting a cultural assessment on a newly admitted client. What component(s) is involved in a cultural assessment? Select all that apply environmental control biologic variations time orientation family support communication physical space or distance

physical space or distance communication time orientation biologic variations environmental control

A psychiatric-mental health nurse develops a plan that identifies strategies and alternatives to assist the client in attainment of expected outcomes. Which standard of practice is the nurse utilizing? implementation outcomes identification planning assessment

planning Explanation: During the planning standard of practice, the nurse develops a plan that prescribes strategies and alternatives to assist the client in attainment of expected outcomes. During the assessment standard of care, the PMH nurse collects and synthesizes comprehensive health data that are pertinent to the client's health and/or situation. During the outcomes identification standard of care, the PMH nurse identifies expected outcomes and the client's goals for a plan individualized to the client or to the situation. During the implementation standard of care, the PMH nurse implements the specified plan.

A client diagnosed with major depressive disorder is admitted to the psychiatric mental-health unit. The client is observed moving slowly while walking and completing activities of daily living. Which physical finding would the nurse document as observed in the client? neologisms waxy flexibility psychomotor retardation automatisms

psychomotor retardation Explanation: Psychomotor retardation is a term used to describe overall slowed movements in a client. Automatisms is a term used for repeated purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair, or tapping the foot. Waxy flexibility is a term used for maintenance of posture or position over time even when it is awkward or uncomfortable. Neologisms is a term used to describe invented words that have meaning only to the client. Therefore, the nurse would document psychomotor retardation as being observed in this client.

A nurse is caring for a client receiving psychoneuroimmunology-based interventions and does not understand the provider's orders. What is the best way for psychiatric-mental health nurses to stay abreast of new knowledge in the mental health field? asking the nurse manager reading journal articles reading layman websites asking the health care providers

reading journal articles Explanation: One of the challenges that psychiatric-mental health (PMH) nurses face is staying abreast of new knowledge emerging in the mental health field. Accessing new information through journals, electronic databases, and continuing education takes time and vigilance, but provides a sound basis for application of new knowledge. Asking the nurse manager, asking the health care providers, and reading layman websites may not provide accurate, research-based information necessary to care for the client effectively and safely.

A 13-year-old client is being assessed by the psychiatric-mental health nurse. Upon assessment, the client reveals that they believe that the world is aggressive and threatening and they respond likewise. Which aspect of the assessment would the nurse document the findings in the medical record? general appearance and motor behavior mood and affect self-concept thought process and content

thought process and content Explanation: An assessment consists of multiple components. Within the general appearance and motor behavior component, the nurse assesses the client's appearance, speech, and motor behavior. These aspects are typically normal for the age group but may be somewhat extreme (e.g., body piercings, tattoos, hairstyle, clothing). These clients often slouch and are sullen and unwilling to be interviewed. They may use profanity; call the nurse or provider names; and make disparaging remarks about parents, teachers, police, and other authority figures. Within the mood and affect components, the nurse assesses the client's emotions and facial expressions. Irritability, frustration, and temper outbursts are common. Within the thought process and content section, the nurse assesses the client's thinking patterns and worldview. In this section, the client may perceive the world to be aggressive and threatening, and they respond likewise. Clients may be preoccupied with looking out for themselves and behave as though everyone is "out to get me." Finally, within the self-concept section, the nurse assesses the client's self-esteem, which is typically low. In the scenario, the nurse would document the findings in the thought process and content section of the assessment.

The nursing instructor is talking to a class of nursing students about the American's with Disabilities Act, and persons having various disabilities that have the right to education in the least restrictive environment. The nursing instructor asks the students, "what is the reason for the least restrictive environment?" Which example should the student nurse choose? budget factors unique needs availability of space placement options

unique needs Explanation: Least restrictive environment means the individual cannot be restricted to an institution when he or she can be successfully treated according to the client's needs, and stay in the community. Budget factors, placement options, and availability of space are not factors related to The American's with Disabilities Act.

The nurse is performing a mental health status examination for a client. Which question will the nurse ask that best determines orientation? "Can you tell me what it means when I say, 'People who live in glass houses shouldn't throw stones.'" "If you found a stamped addressed envelope on the ground, what would you do?" "Why do you feel as though it is your spouse's fault that you drink?" "Can you tell me your name and where you are at the present time?"

"Can you tell me your name and where you are at the present time?" Explanation: One of the most basic assessments of cognitive function is the client's orientation to person, place, and time. Judgment may be viewed as the action-oriented counterpart to insight. To assess abstract reasoning, the nurse may ask the client to describe the meaning of well-known proverbs. Insight is the cognitive process of understanding.

During assessment of a client with schizophrenia, the nurse notes the client has ideas of reference. Which statement of the client would have led the nurse to conclude this? "My family is taking my thoughts away. I am unable to think now." "The news of the terrorist attack is directed to me. The terrorists are trying to warn me." "I am sure you know what I am thinking. Everybody knows what I am thinking." "My dead friend is putting these ideas in my mind."

"The news of the terrorist attack is directed to me. The terrorists are trying to warn me." Explanation: Ideas of reference are the inaccurate perception of the client that general events are personally directed to him or her. Thinking that the news of the terrorist is a warning to the client indicates that the client has ideas of reference. The delusion that other people (dead friend) are putting thoughts in the client's mind is referred to as thought insertion. The delusion that others are taking the client's thoughts away is referred to as thought withdrawal. The delusion that others know what the client is thinking is referred to as thought broadcasting.

A client diagnosed with depression states to the nurse, "I can't rely on anyone. People just do what they want without thinking of other people." Which Erikson's stage of psychosocial development does the nurse identify for the client? trust versus mistrust generativity versus stagnation autonomy versus shame and doubt intimacy versus isolation

trust versus mistrust Explanation: According to Erikson's psychosocial development theory, people can get "stuck" in any stage of development. If the client can overcome the trust versus mistrust stage, they will view the world as safe and reliable, and view relationships as nurturing, stable, and dependable. The client is making a statement of mistrust; therefore, the nurse would identify that the client is in the trust versus mistrust psychosocial development stage. - The autonomy versus shame and doubt stage focuses on achieving a sense of control and independence. - The intimacy versus isolation stage focuses on forming adult, loving relationships, and meaningful attachment to others. - The generativity versus stagnation stage focuses on establishing the next generation.

The client asks about a new medication, it's side effects, cost and if the drug is compatable with the other medication the client takes. The nurse answers all questions the client asks without withholding information. The nurse is guided by which ethical principle? justice beneficence fidelity veracity

veracity Explanation: Veracity is the duty to be honest or truthful. The nurse is exercising veracity when fully answering any questions the client is answering without withholding information. Justice, beneficence and fidelity are not the ethical principle described in this question.

A nurse is initiating a relationship with a new client. After meeting, the nurse makes arrangements to visit again around lunchtime. A colleague invites the nurse to go to the gym with them during lunch. The nurse decides to forgo the gym and talk with the client. The nurse's decision reflects which ethical principle? Autonomy Veracity Beneficence Fidelity

Fidelity Explanation: Fidelity is faithfulness to obligations and duties. It is keeping promises. Fidelity is important in establishing trusting relationships. With autonomy, each person has the fundamental right of self-determination. According to the principle of beneficence, a health care provider uses knowledge of science and incorporates the art of caring to develop an environment in which individuals achieve their maximal health care potential. Veracity is the duty to tell the truth.

While talking with a schizophrenic client, the nurse observes that the client is looking straight ahead, maintains no eye contact, and shows no facial expression, even though the client is telling the nurse about a very emotional episode the client just experienced with a roommate. When describing the client's affect, the nurse documents it as what? Labile Constricted Flat Blunted

Flat Explanation: The client's affect, or facial expression, would be described as "flat." -Labile affect is the abnormal fluctuation or variability of one's expressions, such as repeated, rapid, or abrupt shifts. - Constricted affect relates to a reduction in one's expressive range and intensity of affective responses. - Blunted affect is a severe reduction or limitation in the intensity of one's affective responses to a situation.

A nurse assesses a 29-year-old client in the outpatient mental health clinic. The nurse notes the client is speaking very quickly and jumping from topic to topic very rapidly. There is some connection between ideas, but they are difficult to follow. Which term most accurately describes this thought process? Derailment Circumstantiality Incoherence Flight of ideas

Flight of ideas Explanation: This represents flight of ideas, because the ideas are connected in some logical way. - Derailment, or loosening of associations, has more disconnection within clauses. - Circumstantiality is characterized by the patient speaking "around" the subject and using excessive detail, though thoughts are meaningfully connected. - Incoherence lacks meaningful connection and often has odd grammar or word use. Although severe flight of ideas can produce this condition, evidence is not present in this vignette.

A 20-year-old client who has a diagnosis of schizophrenia frequently experiences delusions of persecution. At the prompting of the client's mother, the nurse attempts to determine the character and severity of these delusions on a particular day. In doing so, the nurse is conducting what type of assessment? Comprehensive Screening Secondary Focused

Focused Explanation: A focused assessment includes the collection of specific data regarding a particular problem as determined by the client, a family member, or a crisis situation. A comprehensive assessment is broader in scope, while a screening assessment aims to identify the presence or absence of health problems.

A home health nurse is documenting and meeting with their supervisor about the client's home visit. Which phase of the home visit does the nurse identify that includes documentation and reporting? postvisit previsit greetings closure

postvisit Explanation: The postvisit phase includes documentation, reporting, and follow-up planning. This is also when the nurse meets with the supervisor and presents data from the home visit at the team meeting. The nurse in the scenario is documenting and meeting with the supervisor is in the postvisit phase. The previsit phase includes setting goals for the home visit based on data received from other health care providers or the client. The greeting and closure phases occur during the actual visit. The greetings phase includes greeting the client and family. The closure phase ends the home visit with the client. The previsit, greetings, and closure phases do not encompass documentation and reporting after the client visit.

A newly hired psychiatric-mental health nurse has learned about the suicide risk assessment. Which statement made by the nurse would indicate a need for further teaching? "Asking clients if they are having suicidal thoughts may put that idea into their head." "It's okay that I feel uncomfortable asking clients about suicidal thoughts." "A suicide risk assessment is part of our comprehensive assessment." "It is our responsibility to keep all clients safe on the unit; therefore, we have to assess for suicidal risk."

"Asking clients if they are having suicidal thoughts may put that idea into their head." Explanation: Self-awareness is crucial when a nurse is trying to obtain accurate and complete information from the client during the psychosocial assessment process. The nurse may feel uncomfortable about certain topics, such as sexuality and suicide, and it is acceptable to hold differing feelings and beliefs about these topics; however, the nurse must remain nonjudgmental and accepting of the client's views and beliefs to maintain a therapeutic relationship with the client. A common misconception that new nurses may hold includes believing if the nurse asks about suicidal thoughts in the client, the client will then act on that thought. Therefore, the nurse's statement, "Asking clients if they are having suicidal thoughts may put that idea into their head", would indicate a need for further teaching. The nurse's statements, "It's okay that I feel uncomfortable asking clients about suicidal thoughts", "It is our responsibility to keep all clients safe on the unit; therefore, we have to assess for suicidal risk", and "A suicide risk assessment is part of our comprehensive assessment", indicates effective teaching.

The nurse is performing an initial assessment for a client newly admitted to the behavioral health unit. When initiating the assessment, which question will the nurse ask to obtain the most relevant data? "Have you thought about which goals that you would like to achieve while you are here?" "Are you feeling well today?" "Discuss with me what brought you in to the behavioral health unit today?" "Do you live at home alone or with family?"

"Discuss with me what brought you in to the behavioral health unit today?" Explanation: The nurse should use open-ended questions when gathering assessment data from the client. Doing so allows the client to begin as they feel comfortable and also gives the nurse an idea about the client's perception of their situation. When asking the client to discuss what brought them to the unit, an opportunity exists to discover more information. The other questions asked are closed-ended, do not elicit more information, and can be responded to in a yes or no response.

A client being evaluated in the clinic for depression lacks ambition and is unemployed. The client states, "Even if I tried to get a job, nobody would want to hire me." What statement made by the nurse would be empowering for the client? "Have you held a stable job previously?" "How long have you been lacking motivation to get a job?" "Have you known anyone who had challenges, but overcame those challenges?" "What strategies have you tried to overcome the depression?"

"Have you known anyone who had challenges, but overcame those challenges?" - Self-efficacy is the belief that personal abilities and effects affect the events in one's life. People with low self-efficacy have low aspirations, experience self-doubt, and may experience anxiety and depression. - Empowering the individual with low self-efficacy include experiencing success or mastery in overcoming obstacles, observing people who have been successful overcoming challenges, persuading people to believe in themselves, and reducing stress and interpreting physical sensations in a positive way. - The client in the scenario has low self-efficacy. Therefore, the nurse's question, "Have you known anyone who had challenges, but overcame those challenges?" would be encouraging the client to reflect on another person's success to learn from the experience. -

A nurse is counseling a client experiencing depressed mood and low self-esteem. Which statement made by the nurse would assess the client's self-concept? "Please elaborate on your support network." "Please describe yourself." "Please describe your family." "What do you like about other people in your life?

"Please describe yourself." Explanation: Self-concept is the way one views oneself in terms of personal worth and dignity. To assess a client's self-concept, the nurse can ask the client to describe themselves, what personal characteristics they like, and what they would change. Therefore, the nurse's statement, "Please describe yourself" would assess the client's self-concept. The nurse's statements, "Please describe your family" and "Please elaborate on your support network" would be assessing the client's support system. The nurse's statement, "What do you like about other people in your life?" is focused on other people, not the client's self-concept.

During assessment of a client with schizophrenia, the nurse notes the client has ideas of reference. Which statement of the client would have led the nurse to conclude this? "I am sure you know what I am thinking. Everybody knows what I am thinking." "My family is taking my thoughts away. I am unable to think now." "The news of the terrorist attack is directed to me. The terrorists are trying to warn me." "My dead friend is putting these ideas in my mind."

"The news of the terrorist attack is directed to me. The terrorists are trying to warn me." Explanation: Ideas of reference are the inaccurate perception of the client that general events are personally directed to him or her. Thinking that the news of the terrorist is a warning to the client indicates that the client has ideas of reference. The delusion that other people (dead friend) are putting thoughts in the client's mind is referred to as thought insertion. The delusion that others are taking the client's thoughts away is referred to as thought withdrawal. The delusion that others know what the client is thinking is referred to as thought broadcasting.

The interdisciplinary team caring for a client diagnosed with depression is having daily meetings about the client's plan of care. What could the nurse say to protect the client from unwarranted use of paternalism in their care? "The client has a right to their privacy." "We need to treat the client with dignity and respect regardless of their values." "We need to truthfully tell the client their plan of care." "We should involve the client in the decision-making process."

"We should involve the client in the decision-making process." Explanation: Paternalism is an approach that assumes that because professionals have specialized knowledge and education, they are best equipped to make decisions for others. Nurses protect against unwarranted use of paternalism by encouraging client, family, and community involvement in decisions. Therefore, the nurse's statement "We should involve the client in the decision-making process" demonstrates the nurse's advocacy to ward against unwarranted paternalism in the care of the client. The statement "The client has a right to their privacy" is advocating for the client's right to autonomy. The statement "We need to treat the client with dignity and respect regardless of their values" is advocating for the client's right to justice. The statement "We need to truthfully tell the client their plan of care" is advocating for the client's right to veracity.

An adult client was born as a female gender but has a male gender identity. Which statement by the nurse demonstrates a therapeutic approach of respecting the client's gender identity? Asking "do you go by he, she, or they?" what led to this hospital admission?" "what brings you in today?" "What pronouns do you go by?"

"What pronouns do you go by?" Many people in the LGBTQIA+ community avoid seeking health care due to fear of discrimination. Health care professionals must utilize gender-neutral communication to reduce stigma and discrimination. Asking about what pronouns someone goes by is the best option because it demonstrates a nonjudgmental approach and inquires how the client would like to be addressed. Asking "do you go by he, she, or they?" limits the choices and is not an open-ended question for the client to answer. Asking "what led to this hospital admission?" does not speak to the client's gender identity. Asking "what brings you in today?" begins the assessment process, which comes after establishing rapport and trust with the client.

The nurse is performing a mental health status examination for a client. Which question asked by the nurse indicates that the nurse is assessing the judgment of the client? "In which country do you live?" "What would you do if you found $10 on the side of the road?" "Could you please repeat the days of the week backward?" "Could you please explain the meaning of proverb 'barking dogs seldom bite'?"

"What would you do if you found $10 on the side of the road?" Explanation: Judgment is the ability to understand one's environment and situation correctly and to adapt one's behavoir and decisions accordingly. To determine if the client is able to make just decisions, the nurse should present a hypothetical scenario like "What would you do if you found $10 on the side of the road?" Questions such as "In which country do you live?" should be asked while assessing the memory of the client. Questions such as "Could you please repeat the days of the week backward?" should be asked while assessing the client's ability to concentrate. Questions such as "Could you please explain the meaning of the proverb 'barking dogs seldom bite'?" should be asked by the nurse while assessing the abstract thinking abilities of the client.

A client diagnosed with bipolar disorder has stopped taking their medications due to "having a lot of side effects." What action made by the provider would the nurse anticipate for the client? stopping the medication lowering the dose of the medication reassessing the client in 4 weeks increasing the dose of the medication

. lowering the dose of the medication Explanation: Genetic differences can affect a client's response to treatment, specifically psychotropic medications. People differ in the metabolism and efficacy of the medications and may be poor, intermediate, or an ultra-rapid metabolizer. People who are poor metabolizers have more of the medication in their system for longer and may have increased side effects. The dose of the medication would likely need to be lowered to decrease the side effects and continue to produce the desired response. The client in the scenario is having a lot of side effects and is threatening noncompliance. Therefore, the nurse would anticipate the provider to lower the dose of the medication. Increasing the dose of the medication would increase the side effects that the client is experiencing. Stopping the medication would cause the client's mood to become unstable. Reassessing the client in 4 weeks may be necessary, but the client should remain on the medication due to having a chronic mental illness that needs to be treated.

A client with persistent depression is considering electroconvulsive therapy (ECT). The nurse has seen ECT be effective in other cases. When the client expresses fear and doubt about undergoing ECT, the nurse tries to talk the client into it, because the nurse truly believes it will help the client. Which two ethical concepts are in conflict? Beneficence and fidelity Justice and autonomy Beneficence and autonomy Fidelity and paternalism

Beneficence and autonomy Explanation: Beneficence and autonomy are in conflict. Beneficence is practicing with the intent to do good; however, professionals define how to do good, which may override the wishes and self-determination of the client. Autonomy is the client's right to make decisions for himself or herself. Justice refers to fairness; that is, treating all people fairly and equally without regard for social and economic status, race, sex, marital status, religion, ethnicity and cultural beliefs. Fidelity is the nurse's faithfulness to duties, obligations, and promises.

A nurse is preparing an educational program identifying the major barriers experienced by culturally diverse populations when accessing mental health services. Which information should the nurse include? (Select all that apply.) Group value systems are not mutually accepted Health care beliefs are not shared by both client and health care provider North American health care systems are biased against the culturally diverse client Client and health care provider do not share a common language Cultural beliefs in people of varying ethinicities prevent people from accepting health care

Client and health care provider do not share a common language Health care beliefs are not shared by both client and health care provider Group value systems are not mutually accepted Research has shown that the important reasons for the underuse of mental health services by members of diverse ethnic groups include language barriers, varying beliefs regarding health and wellness, and diverse values regarding health and wellness. Bias by American health care systems is not a major factor in the culturally diverse client's ability or willingness to access health care. The nurse would communicate an attitude of ethnocentrism if he or she were to include that beliefs of some cultural ethnicities prevent people from accepting health care.

Which must be addressed to establish a trusting working relationship before proceeding with the assessment? Client's feelings and perceptions Client's compliance Client's willingness to participate Client's behavior

Client's feelings and perceptions Explanation: The nurse must address the client's feelings and perceptions to establish a trusting working relationship before proceeding with the assessment.

Which component of hardiness encompasses the ability to make appropriate decisions in life activities? Change Challenge Control Commitment

Control Explanation: Control is the ability to make appropriate decisions in life activities. Commitment (su cam ket) is active involvement in life activities. Challenge is the ability to perceive change as beneficial rather than just stressful. Change is not a component of hardiness, according to Kobasa (1979).

Which represents the best brief definition of culture? Culture refers to a person's religious beliefs. Culture refers to a person's racial background. Culture is a society's social norms. Culture is shared attitudes, customs, and beliefs.

Culture is shared attitudes, customs, and beliefs. Explanation: Members of groups share an accepted way of life that provides a general structure for living, as well as patterns by which they interpret reality. The structure includes all of the socially learned behaviors, values, beliefs, customs and ways of thinking of a population that guide its members' views of themselves and the world.

A mental health nurse is caring for a client with schizophrenia. The nurse observes the client laughing about the recent death of the client's father. The nurse would correctly document this mood as what? Incongruent Blunted Labile Flat

Incongruent Explanation: The correct answer is incongruent affect or lack of harmony between one's voice and movements with one's speech or verbalized thoughts. - Blunted affect is a severe reduction or limitation in the intensity of one's affective responses to a situation. - Flat affect describes absence or near absence of any signs of affective responses. -Labile affect is the abnormal fluctuation of one's expressions.

A nurse who provides care in a large, urban hospital identifies the large influence of culture on health. Which action will the nurse take to integrate culture to enhance the delivery of care? A. Develop close relationships with clients. B. Role model healthy behaviors and priorities. C. Incorporate beliefs, values, and behavioral traditions into care. D. Integrate knowledge, skills, and norms.

Incorporate beliefs, values, and behavioral traditions into care. Explanation: Culture is defined in many ways, but at the broadest level, it can be understood to be a system of beliefs, values, and behavioral expectations that provide social structure for daily living. These beliefs, values, and expectations frequently direct other aspects of an individual's life such as thinking, behavior, dress, and diet, but these are not the central components of the concept of culture.

A client being counseled for anger management has threatened to kill one of their family members by stabbing them. What is the nurse's priority intervention? Inform the health care team and family member of the threats. Remain calm and allow the client to express their feelings. Teach the client effective coping skills to avoid violence. Maintain client confidentiality and do not share this information with the client's family.

Inform the health care team and family member of the threats. Explanation: When a client makes specific threats or has a plan to harm another person, health care providers are legally obligated to warn the person who is the target of the threats or plan. The legal term for this informing process is duty to warn. This is a situation where the nurse must breach client confidentiality to protect the threatened person. Therefore, the nurse's priority intervention is to inform the health care team and family member of the threats. - Confidentiality must be broken in these situations; therefore, the nurse must not maintain client confidentiality and keep this information from the client's family. - The nurse should remain calm and allow the client to express their feelings and teach the client effective coping skills to avoid violence, but these actions should come after the nurse informs the health care team and the threatened family member.

One way that nurses can protect themselves against liability from malpractice is to do what? Carry individual malpractice insurance. Request legal consultation from the employer. Know the statutory and professional standards. Avoid documenting incriminating information.

Know the statutory and professional standards. Explanation: To decrease their chances of liability for malpractice, psychiatric nurses must ensure that their professional practice is within the bounds of statutory and professional standards

A client with psychosis who was recently admitted to a psychiatric unit says to the nurse, "The car is red. Are you ready for lunch? My head is hurting. Dogs bark loud." The client is exhibiting which type of speech? Neologism Loose associations Clang association Echolalia

Loose associations Explanation: Looseness of association is a disturbance of thinking shown by speech in which ideas shift from one unrelated or minimally unrelated subject to another. Echolalia is the parrot-like repetition of overheard words or phrases. Clang association is a type of thinking in which the sound of a word (rhyming) substitutes for logic during communication. Neologism describes the use of a new word or combination of several words coined or self-invented by a person and not readily understood by others.

Children of parents who abused alcohol and substances are able to develop self-esteem and self-efficacy by developing which characteristics? Tolerance Resilience Hardiness Social skills

Resilience Explanation: - Resilience is having healthy responses to stressful situations or risky environments. - Hardiness is the ability to resist illness when under stress. - Social skills are a type of coping strategy. - Tolerance is the ability to deal with increasing levels of stress in an adaptive way.

The nurse is assessing a client who recently immigrated to the United States. The client is experiencing a high level of stress and reports that nobody in the workplace is willing to work with or talk to the client. What is the most likely cause of stress in the client? Low self-efficacy Low sense of belonging Low hardiness Low resilience

Low sense of belonging Explanation: Sense of belonging is the feeling of connectedness in a social environment. It means that an individual should feel valued and worthwhile in his or her support system. Support system also includes the client's workplace. In this situation, the client does not feel accepted in the workplace and thus the client has a reduced sense of belonging. The particular situation does not indicate that the client has low hardiness, low efficacy, or reduced resilience. - Hardiness refers to the ability to resist illness when under stress. -Self-efficacy refers to the belief that personal abilities and efforts will affect the events in our lives. - A resilient individual exhibits healthy responses in stressful circumstances.

While performing the admission assessment of a new client, the nurse observed that the client brought a bottle of over-the-counter pain medication to the hospital. The nurse failed to document this or remove the medication from the room. Subsequently, the client experienced a serious adverse drug reaction as a result of the interaction between this drug and one of the drugs that the client was prescribed in the hospital. This nurse may be guilty of what? Assault Incompetence Failure of duty to warn Malpractice

Malpractice Explanation: The four elements of nursing malpractice are evident in this scenario. Assault is an act that puts another person in apprehension of being touched (or of bodily harm without consent), and failure of duty to warn surrounds a client's threat to harm another person. Incompetence, in the legal sense, surrounds a client's right to autonomy.

When asking a client to "tell me how having schizophrenia has affected your life," the nurse is assessing the client's capacity for what? Intellectual thought Critical thinking Concrete thinking Reflective insight

Reflective insight Explanation: Insight is defined as self-understanding, or the extent of one's understanding about the origin, nature, and mechanisms of one's attitudes, behavior, and/or condition. Thus, asking a client how schizophrenia has affected his or her life is an example of assessing reflective thinking. Critical thinking (determining the meaning and significance of what is observed or expressed) intellectual ability (a person's ability to use facts comprehensively), concrete thinking (seeing each situation as unique and lacking the ability to generalize from the similarities between situations) are not the functions being assessed.

Children of parents who abused alcohol and substances are able to develop self-esteem and self-efficacy by developing which characteristics? Hardiness Resilience Social skills Tolerance

Resilience Explanation: Resilience ( kha năngg phụcc hồii ) is having healthy responses to stressful situations or risky environments. Hardiness is the ability to resist illness when under stress or the ability to endure difficult conditions. Social skills are a type of coping strategy. Tolerance ( suc chịu đựng) is the ability to deal with increasing levels of stress in an adaptive way.

During an assessment, which would be the most important question topic? History Suicidal ideation Motor behavior Roles and relationships

Suicidal ideation Explanation: The client's safety is a priority. Asking clients clearly and directly about suicidal ideation is essential.

The nurse is performing an assessment of a client with a psychiatric illness. The nurse has 10 cards with different inkblot shapes. Which test is the nurse about to perform? The Thematic Apperception Test The Psychological Screening Inventory The Rorschach Test The Tennessee Self-Concept Scale

The Rorschach Test Explanation: The Rorschach Test is a projective personality test. It includes the use of 10 stimulus cards with inkblots. The client has to describe perceptions of inkblots. This test is useful to understand the coping styles, interpersonal attitudes, and characteristics of ideation. - The Thematic Apperception Test uses 20 stimulus cards with pictures. The client tells a story about the picture. - The Tennessee Self-Concept Scale and the Psychological Screening Inventory are objective personality tests. The Tennessee Self-Concept Scale includes 100 true-false questions that provide information on 14 scales related to self-concept. - The Psychological Screening Inventory consists of 103 true-false questions. The result of the test indicates whether the client needs psychological help.

The mental health nurse is interviewing a client of a different cultural background regarding the client's health care practices. The nurse understands that cultural competence is important in the care of this client. Cultural competence in health care can be best described as what? The ability to understand and effectively interact with individuals or members of a community from diverse cultural or ethnic backgrounds A combination of a person's beliefs about cultural values and knowledge about his or her own culture Knowing the characteristics of each individual cultural group in America The client's ability to tell the health care provider about his or her cultural beliefs and practices

The ability to understand and effectively interact with individuals or members of a community from diverse cultural or ethnic backgrounds Explanation: Cultural competence involves the desire and attempt by health care workers to learn about and work within the cultural context of the client from a diverse cultural or ethnic background.

The nurse at a mental health clinic is performing the initial assessment of a client who emigrated from Mexico several years ago. The client, who seems reluctant to speak, is accompanied by their more talkative adult child. The nurse has never cared for someone of Mexican descent. Which individual should the nurse regard as the best source of information for providing competent care for the client? A fellow nurse who speaks Spanish fluently The client The client's child A fellow nurse whose spouse is of Mexican descent

The client Explanation: To provide culturally competent care, the nurse must find out as much as possible about a client's values, beliefs, and health practices. Because individual differences exist among people from the same cultural background—perhaps even within the same family—the client is the best source for that information. If the client seems reluctant to speak, the nurse should employ therapeutic communication techniques to try to get the client to share the necessary information. The adult child may be of some help but is not as reliable a source of information as the client. The coworker whose spouse is of Mexican descent is likely to be of little help; even if the coworker is very familiar with the spouse's beliefs, those beliefs aren't necessarily shared by the client merely because of the similar heritage. Additionally, fluency in a shared language isn't an indication of cultural awareness, let alone knowledge of an individual's preferences or beliefs.

The nurse is caring for a client who, because of cultural beliefs, attributes their anxiety to a supernatural cause. When developing a plan of care for this client, which information would be most important for the nurse to keep in mind? The client will have difficulty seeing the relationship between their health practices and anxiety. The client will be deeply ashamed of experiencing anxiety. The client has accepted the anxiety as a permanent, untreatable condition. The client will be eager to seek pharmaceutical therapy for the anxiety.

The client will have difficulty seeing the relationship between their health practices and anxiety. Explanation: Clients with unnatural or personal beliefs regarding illness attribute their conditions to the intentional actions of external agents or supernatural forces. These clients don't necessarily see their conditions as permanent. However, because they believe the source to be external, they may be more likely to seek traditional cultural remedies that focus on an outside factor instead of medication or interventions focused on their own health practices. While some cultures may stigmatize mental health issues, potentially causing deep shame or guilt among clients from those backgrounds, the nurse should not automatically assume that is the case.

The nurse has been asked to identify a location to conduct an interview with a psychiatric-mental health client. Which is an essential consideration when choosing a location? The client's right to privacy The amount of lighting in a given location The amount of distracters in a given location The client's right to a stress-free environment

The client's right to privacy Explanation: The client's right to privacy is an essential setting consideration. It is an ethical responsibility of the nurse as well as a legal right of the client. Nurses must make critical clinical judgments about the optimal setting that maintains privacy while also ensuring safety.

The nurse is trying to effectively deal with the spiritual needs of a client. To best meet the client's need, what should the nurse do? clarify own spiritual values and beliefs before exploring clients' beliefs have the healthcare provider deal with spiritual needs have clergy come to see the client ask the manager what to do

clarify own spiritual values and beliefs before exploring clients' beliefs Explanation: The nurse needs to self reflect and live according to one's own beliefs, and then explore other client's beliefs and values. It does not include having clergy come to see the client, asking the manager what to do, or having the healthcare provider deal with spiritual needs.

A psychiatric-mental health client has an advance care directive on their medical record. A clinician provides treatment that disregards the client's directive. The clinician would be liable for which of the following? medical battery battery assault false imprisonment

medical battery Explanation: Failure to respect a client's advance care directive is considered medical battery. Assault is the threat of unlawful force to inflict bodily injury on another. Battery is intentional and unpermitted contact with another. False imprisonment is detention or imprisonment contrary to the provision of law.

A psychiatric-mental health nurse is gathering psychosocial assessment data from a client experiencing anxiety. Upon assessment, the client is restless and cannot concentrate on answering the questions from the nurse. What is the priority intervention from the nurse before proceeding in the interview? assessing the client's support system decreasing the client's anxiety level rescheduling the interview assessing the client's coping ability

decreasing the client's anxiety level Explanation: The client's health status may affect the client's psychosocial assessment. If the client is anxious, the nurse may have difficulty eliciting the client's full participation in the assessment. The nurse needs to recognize these feelings and deal with them before continuing the full assessment. Therefore, the first intervention by the nurse would be to decrease the client's anxiety level. The nurse may need to reschedule the interview, but the priority intervention is to decrease the client's anxiety level before attempting to reschedule. After the client is calmer and can concentrate, the nurse may assess the client's support system and coping ability.

The nurse is caring for a client after having various diagnostic tests. The client discusses a proxy being in attendance for the health care provider's diagnosis. The nurse requests a copy for the file, and allows the proxy to be in attendance with what type of document? informed consent living will patient rights durable power of attorney

durable power of attorney Explanation: A durable power of attorney for health care appoints a proxy (uy quyen) , usually a relative or trusted friend, to make health care decisions on an individual's behalf. The living will, patient rights, and informed consent are not included in the durable power of attorney. A living will is a written statement detailing a person's desires regarding their medical treatment in circumstances in which they are no longer able to express informed consent, especially an advance directive. Patient rights are those basic rule of conduct between patients and medical caregivers as well as the institutions and people that support them. Informed consent is the permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits.

A client has disclosed to the nurse that they feel worried that their child will be hungry because they are unable to provide consistent food to the child. Which social determinants of health category should the nurse assess further? social and community context health care access and quality neighborhood and built environment economic stability

economic stability Explanation: The issues that involve social determinants of health are categorized into health care access and quality, education access and quality, social and community context, economic stability, and neighborhood and built environment. - health care access and quality, issues include access to health care or primary care, health insurance coverage, and health literacy. - neighborhood and built environment, issues include quality of housing, access to transportation, availability of healthy foods, air and water quality, and neighborhood crime and violence. - social and community context, issues include community cohesion, civic participation, workplace conditions, discrimination, and incarceration. - economic stability, issues include poverty, employment, food security, and housing stability. The client feels worried about food security; therefore, the nurse would assess the category of economic stability further.

The nurse educator is discussing spirituality for nurses in a mental health class. The nurse educator asks a student nurse, "Which of the following is most consistent with spirituality?" The student nurse identifies which description? closely intertwined with beliefs about health and mental illness feeling a connection to a higher power living according to one's beliefs participation in common ways of worshiping

feeling a connection to a higher power Explanation: Spirituality develops over time and is a dynamic, conscious process characterized by two movements of transcendence; either deep within the self or beyond the self. Self-transcendence involves self-reflection and living according to one's values in establishing meaning to events and a purpose to life. Closely intertwined with beliefs about health and mental illness, living according to one's beliefs, and participation in common ways of worshipping are not things that are most consistent with spirituality.

A client being counseled for depression states to the nurse, "I just want to help others. I want to help shape the next generation." Based on the statement, which Erikson's stage of psychosocial development does the nurse identify that the client is in? intimacy versus isolation trust versus mistrust ego integrity versus despair generativity versus stagnation

generatively versus stagnation Erikson's psychosocial stage of development - trust versus mistrust focuses on viewing the world as a safe and reliable place. If successful in this stage, the client views relationships as nurturing, stable, and dependable. - The intimacy versus isolation stage focuses on forming adult, loving relationship, and meaningful attachment to others, as well as being creative and productive. - The generatively versus stagnation stage focuses on establishing the next generation. - The ego integrity versus despair stage focuses on accepting responsibility for oneself and life. The client in the scenario is depressed and wants to help shape the next generation; therefore, the nurse identifies that the client is in the generatively versus stagnation stage.

A psychiatric-mental health nurse is gathering a family history from a client. What individual factor to the client's response to illness and treatment is being assessed by the nurse? medication response stage of development genetics and biologic health practices

genetics and biologic Explanation: Individual factors to the client's response to illness and treatment include the client's age, growth, and development; genetics and biologic factors; physical health and health practices; medication response; self-efficacy; hardiness; resilience and resourcefulness; and spirituality. Gathering a family history falls into the category of assessing how the client's genetics and biologic factors will play a role in their response to illness and treatment. A family history is not included in assessing the client's stage of development, health practices, or medication response.

An adolescent client is being counseled for anger management. The client states to the nurse, "I just don't fit in with my family or any kids at school. I am an outcast." What will be the nurse's focus of intervention for this client? increasing a sense of belonging increasing hope and faith increasing the frequency of social contact sharing recreational activities with family members

increasing a sense of belonging Explanation: A sense of belonging is the feeling of connectedness with or involvement in social system or environment of which a person feels an integral part. Two concepts are included with a sense of belonging: value, which is feeling needed and accepted; and fit, which is feeling like they fit within the group. The client is expressing that they don't feel like they fit in with the family or kids at school, which would prompt the nurse to develop interventions to increase a sense of belonging for the client. Increasing the frequency of social contacts would not fill the need for the client and does not necessarily lead to increased emotional support; therefore, it would not be appropriate. Increasing hope and faith would be appropriate if the client's focus problem was a lack of spirituality. Sharing recreational activities with family members would increase family resilience. However, a sense of belonging is the client's main stressor, not family coping; therefore, the intervention of sharing recreational activities with family members would not be appropriate.

Which ethical principles become an issue in mental health when a segment of a population does not have access to health care? nonmaleficence fidelity justice veracity

justice Explanation: Justice is the duty to treat all fairly, distributing the risk and benefits equally. Justice becomes an issue in mental health when a segment of a population does not have access to health care. Basic good should be distributed so the least advantaged members of society benefit. Nonmaleficence, fidelity, and veracity are not being used in this situation.

A client who had agreed to be hospitalized for depression has decided that he/she wants to leave the hospital. The mental health staff caring for the client realizes that at present the client can legally: leave even if doing so is against medical advice (AMA). be retained in the hospital against the client's will. be discharged if evaluated through administrative hearings. leave the hospital after giving written notice of the client's intent to do so.

leave even if doing so is against medical advice (AMA). Explanation: Clients who are not dangerous to themselves or others can leave the hospital against medical advice. The client could not be legally detained in the hospital, or even detained until he/she provides written intent, because there is no indication the client was treated involuntarily. Administrative hearing are unnecessary for a voluntary client to leave the treatment setting.

A client diagnosed with major depressive disorder is admitted to the psychiatric mental-health unit. The client is observed moving slowly while walking and completing activities of daily living. Which physical finding would the nurse document as observed in the client? neologisms waxy flexibility automatisms psychomotor retardation

psychomotor retardation Explanation: Psychomotor retardation is a term used to describe overall slowed movements in a client. Automatisms is a term used for repeated purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair, or tapping the foot. Waxy flexibility is a term used for maintenance of posture or position over time even when it is awkward or uncomfortable. Neologisms is a term used to describe invented words that have meaning only to the client. Therefore, the nurse would document psychomotor retardation as being observed in this client.

A nurse is teaching a client about resourcefulness to improve their mental health. What teaching topic would be included in the client's education on resourcefulness? family rituals ( nghi lễ) and routines self-care activities community integration interpersonal relationships

self-care activities Explanation: Resourcefulness involves using problem-solving abilities and believing that one can cope with adverse or novel situations. Examples of resourcefulness include performing health-seeking behaviors, learning self-care, monitoring one's thoughts and feelings about stressful situations, and taking action to deal with stressful circumstances. - Family rituals and routines would be included in education about family resilience. Community integration and interpersonal relationships would be included in self-efficacy education.

During the assessment of a client who has a pattern of eating-disordered behavior, the nurse asks, "What would you change about your body, if you could?" The nurse is assessing which component of the psychosocial assessment? thought process and content self-concept roles and relationships sensory-perceptual alterations

self-concept Explanation: By asking the question "What would you change about your body, if you could?" the nurse is assessing self-concept. The client's description of self in terms of physical characteristics gives the nurse information about the client's body image which is also a part of self concept. Sensory-perceptual alterations refer to a change in the client's perception of the world. Often this results in hallucinations or a false sensory perception or perceptual experience that does not really exist. When assessing roles and relationships, the nurse would ask questions such as "Do you feel close to your family?" or "Do you have a significant other?" to determine the existence and quality of the client's sources of support and/or stress. Thought process and content refers to how the client thinks and what they actually say. The aim of this component of the assessment is to determine if the client's ability to think is impaired or intact.

A client admitted to the psychiatric-mental health unit needs to make important health care decisions. The client is hesitant and would like to wait for their family to arrive before making any decisions. Which aspect of the cultural assessment should the nurse assess further? social organization communication environmental control time orientation

social organization Explanation: Social organization refers to family structure and organization, religious values and beliefs, ethnicity, and culture, all of which affect a person's role and health and illness behavior. Some people may seek the advice of a friend or a family member or may make most decisions independently. Many people strongly value the role of family in making health care decisions and may delay decisions until they can consult appropriate family members. The client in the scenario would like to wait to make decisions until their family arrives; therefore, the assessment of social organizations would need to be assessed further. Communication refers to the body language and linguistics associated with different cultures. Time orientation refers to the client's beliefs on importance of promptness and punctuality. Environmental control refers to how the client views their behaviors as affecting their health status