Foundations and Practice of Mental Health HESI review

The nurse explains to a nursing assistant that behavior usually is viewed and accepted as normal if it: 1. Fits within standards accepted by one's society 2. Helps the person reduce the need for coping skills 3. Expresses the individual's feelings and thoughts accurately 4. Allows achievement of short-term and long-term goals by the individual

1. Fits within standards accepted by one's society

A young client who has become a mother for the first time is anxious about her new parenting role. With the nurse's encouragement, she joins the new mothers' support group at the local YMCA. What kind of prevention does this activity reflect? 1. Primary prevention 2. Tertiary prevention 3. Secondary prevention 4. Therapeutic prevention

1. Primary prevention

A depressed client often sleeps past the expected time of awakening and spends excessive time resting and sleeping. Which nursing intervention is appropriate for this client? 1. Restricting the client's access to the bedroom 2. Offering the client a series of relaxation tapes 3. Rescheduling the client's bedtime to an earlier hour 4. Suggesting that the client exercise before going to bed

1. Restricting the client's access to the bedroom **The goal is 6 to 8 hours of rest at night; too much time spent sleeping in the daytime will defeat the goal of adequate rest at night.

A client with a diagnosis of borderline personality disorder (BPD) has negative feelings toward the other clients on the unit and considers them all "bad." Which defense is the client using when identifying the other clients thusly? 1. Splitting 2. Ambivalence 3. Passive aggression 4. Reaction formation

1. Splitting

With the client's permission, the nurse should inform the family about what is happening. The main reason for this action is that informed families: 1. Ease the client's anxiety 2. Are better equipped to assist the client 3. Appear more relaxed with the situation 4. Commonly cause fewer nursing problems

2. Are better equipped to assist the client

The way individuals cope with an unexpected hospitalization depends on many factors. However, the one that is most significant is: 1. Cognitive age 2. Basic personality 3. Financial resources 4. General physical health

2. Basic personality

A client on the psychiatric unit is undergoing a pretreatment evaluation for electroconvulsive therapy (ECT). Because of the client's profoundly depressed behavior, the nurse doubts that the client can provide informed consent. What should the nurse's initial intervention be? 1. Consulting with the hospital's legal staff and following their recommendation 2. Having the client verbalize her understanding and the outcomes of the procedure 3. Asking the client to sign the consent form because the client has not been declared incompetent 4. Suggesting to the health care provider that a family member sign the consent form for the client

2. Having the client verbalize her understanding and the outcomes of the procedure

Which psychotherapeutic theory uses hypnosis, dream interpretation, and free association as methods to release repressed feelings? 1. Behaviorist model 2. Psychoanalytical model 3. Psychobiological model 4. Social-interpersonal model

2. Psychoanalytical model

A client sits huddled in a chair and leaves it only to assume the fetal position in a corner. The nurse, observing this, identifies the behavior as: 1. Reactive 2. Regressive 3. Dissociative 4. Hallucinatory

2. Regressive **Curling up in a corner reflects the early fetal position; the individual curls up for both protection and security

A nurse is caring for a client who is experiencing a crisis. Which nervous system is primarily responsible for the clinical manifestations that the nurse is likely to identify? 1. Central nervous system 2. Peripheral nervous system 3. Sympathetic nervous system 4. Parasympathetic nervous system

3. Sympathetic nervous system **The sympathetic nervous system reacts to stress by releasing epinephrine, which prepares the body to fight or flee by increasing the heart rate, constricting peripheral vessels, and increasing oxygen supply to muscles.

After speaking with the parents of a child dying of leukemia, the practitioner gives a verbal do-not-resuscitate order but refuses to put it in writing. What should the nurse do? 1. Follow the order as given by the practitioner 2. Refuse to follow the practitioner's order unless the nursing supervisor approves it 3. Ask the practitioner to write the order in pencil on the child's chart before leaving the room 4. Determine whether the family is in accord with the practitioner while following hospital policy

4. Determine whether the family is in accord with the practitioner while following hospital policy

A young mother of three children, all born 1 year apart, has been hospitalized after trying to hang herself. The client is being treated with milieu therapy. The nurse understands that this therapeutic modality consists of: 1. Providing individual and family therapy 2. Using positive reinforcement to reduce guilt 3. Uncovering unconscious conflicts and fantasies 4. Manipulating the environment to benefit the client

4. Manipulating the environment to benefit the client

What developmental task should the nurse consider when caring for toddlers? 1. Trust 2. Industry 3. Autonomy 4. Identification

3. Autonomy

How long after the last dose should the nurse schedule to have a client's blood drawn to evaluate the serum lithium level? 1. 2 to 4 hours 2. 4 to 6 hours 3. 6 to 8 hours 4. 8 to 12 hours

4. 8 to 12 hours

The nurse should first discuss terminating the nurse-client relationship with a client during the: 1. Working phase, when the client initiates it 2. Orientation phase, when a contract is established 3. Working phase, when the client shows some progress 4.Termination phase, when discharge plans are being made

2. Orientation phase, when a contract is established

One morning a client tells the nurse, "My legs are turning to rubber because I have an incurable disease called schizophrenia." The nurse identifies that this as an example of: 1. Hallucinations 2. Paranoid thinking 3. Depersonalization 4. Autistic verbalization

3. Depersonalization

Certain questions are applicable in determining nursing negligence. (Select all that apply.) 1. "Was reasonable care provided?" 2. "Was there a breach of nursing duty?" 3. "Was there an act of omission that resulted in harm? 4. "Except for the nurse's action, would the injury have occurred?" 5. "Did the nurse fully understand the actions would result in harm?"

1. "Was reasonable care provided?" 2. "Was there a breach of nursing duty?" 3. "Was there an act of omission that resulted in harm? 4. "Except for the nurse's action, would the injury have occurred?"

For which adverse effect should the nurse continually observe a client who is receiving valproic acid (Depakene)? 1. Yellow sclerae 2. Motor restlessness 3. Ringing in the ears 4. Torsion of the neck

1. Yellow sclerae **Yellow sclerae are a sign of jaundice; pancreatitis and hepatic failure are life-threatening adverse effects of valproic acid (Depakene).

The parents of a toddler with recently diagnosed moderate cognitive impairment discuss their child's possibility of future independent function. What should the nurse conclude? 1. They accept the child's diagnosis. 2. Denial is being used as a defense. 3. They want to explore their child's limitations. 4. Intellectualization helps them put the diagnosis into perspective.

2. Denial is being used as a defense.

A child in the first grade is murdered, and counseling is planned for the other children in the school. What should a nurse identify first before evaluating a child's response to a crisis? 1. Developmental level of the child 2. Quality of the child's peer relationships 3. Child's perception of the crisis situation 4. Child's communication patterns with family members

1. Developmental level of the child **Rationale: Knowledge of the developmental level is essential to understanding a child's response to a crisis situation; the variety of coping abilities usually increases as the child progresses through the stages of growth and development.

What should a nurse recognize that a client who uses the defense mechanism of sublimation is doing? 1. Acting out in reverse something already done or thought 2. Returning to an earlier, less mature stage of development 3. Channeling unacceptable impulses into socially approved behavior 4. Excluding from consciousness thoughts that are psychologically disturbing

3. Channeling unacceptable impulses into socially approved behavior

What should the nurse do to develop a trusting relationship with a disturbed child who acts out? 1. Ask the child's feelings about the parents 2. Implement one-on-one interactions every half hour 3. Offer support and encourage safety during play activities 4. Begin setting limits and explain the rules that must be followed

3. Offer support and encourage safety during play activities

What statement by a 45-year-old woman scheduled for an abdominal hysterectomy and bilateral salpingo-oophorectomy should alert the nurse to the potential for postoperative coping difficulties? 1. "I'm not the least bit worried." 2. "I don't want any more children." 3. "I get along very well with my husband." 4. "I'll be glad not to have any more periods."

1. "I'm not the least bit worried." **Not being worried indicates potential denial and possible failure to address the problem emotionally

The nurse is working with a client who talks freely about feeling depressed. During the interaction the client states, "Things will never change." What findings support the nurse's conclusion that the client is experiencing hopelessness? (Select all that apply.) 1. Bouts of crying 2. Self-destructive acts 3. Presence of delusions 4. Feelings of worthlessness 5. Intense interpersonal relationships

1. Bouts of crying 2. Self-destructive acts 4. Feelings of worthlessness

A psychiatric nurse is hired to work in the psychiatric emergency department of a large teaching hospital. While reviewing the manuals, the nurse reads, "People with mental health emergencies shall be triaged within 5 minutes of entering the emergency department." What does the nurse consider this statement to represent? 1. Hospital policy 2. Standard of care 3. Hospital procedure 4. Mental Health Bill of Rights

1. Hospital policy

A nurse is teaching clients about dietary restrictions during monoamine oxidase inhibitor (MAOI) therapy. What response does the nurse tell them to anticipate if they do not follow these restrictions? 1. Occipital headaches 2. Generalized urticaria 3. Severe muscle spasms 4. Sudden drop in blood pressure

1. Occipital headaches

When intimate partner violence (IPV) is suspected, the nurse plays an important role as an advocate for the victim. The advocate role includes several important components. (Select all that apply.) 1. Planning for future safety 2. Normalizing victimization 3. Validating the experiences 4 .Promoting access to community services

1. Planning for future safety 3. Validating the experiences 4 .Promoting access to community services

Amitriptyline (Elavil) is an antidepressant medication used to treat anxiety disorders. Which class of antidepressant medications does it belong to? 1. Tricyclics 2. Monoamine oxidase inhibitors (MAOIs) 3. Selective serotonin reuptake inhibitors (SSRIs) 4. Serotonin-norepinephrine reuptake inhibitors (SNRIs)

1. Tricyclics

According to Erikson, a child's increased vulnerability to anxiety in response to separation or pending separation from significant others results from failure to complete a developmental stage. What does the nurse call this stage? 1. Trust 2. Identity 3. Initiative 4. Autonomy

1. Trust

A woman who is emotionally and physically abused by her husband calls a crisis hotline for help. The nurse works with the client to develop a plan for safety. What should be included in the safety plan? (Select all that apply.) 1. Limiting contact with the abuser 2. Determining a safe place to go in an emergency 3. Memorizing the domestic violence hotline number 4. Obtaining a bank loan to finance leaving the abuser 5. Arranging for a family member to assist her in leaving

2. Determining a safe place to go in an emergency 3. Memorizing the domestic violence hotline number

After several interactions with a client, the nurse at the mental health clinic identifies a pattern of withdrawal and nonparticipation in situations requiring communication with others. In which area should the nurse expect the client to have difficulty? 1. Personal identity 2. Social interaction 3. Sensory perception 4. Verbal communication

2. Social interaction

A client asks the nurse how psychotropic medications work. The nurse correctly replies: 1. "These medications decrease the metabolic needs of your brain." 2. "These medications increase the production of healthy nervous tissue." 3. "These medications affect the chemicals used in communication between nerve cells." 4. "These medications regulate the sensory input received from the external environment."

3. "These medications affect the chemicals used in communication between nerve cells."

The nurse is caring for a client experiencing a crisis. What role is most important for the nurse to assume when providing therapeutic crisis intervention? 1. Passive listener 2. Friendly adviser 3. Active participant 4. Participant observer

3. Active participant

A client is receiving a monoamine oxidase inhibitor (MAOI). What should the nurse teach the client? 1. It is necessary to avoid the sun. 2. Drowsiness is an expected side effect of this medication. 3. The therapeutic and toxic levels of the drug are very close. 4. Many prescribed and over-the-counter drugs cannot be taken with this medication

4. Many prescribed and over-the-counter drugs cannot be taken with this medication

Methylphenidate (Ritalin) is prescribed to treat a 7-year-old child's attention deficit-hyperactivity disorder (ADHD). The nurse understands that methylphenidate is used in the treatment of this disorder in children for its: 1. Diuretic effect 2. Synergistic effect 3. Paradoxical effect 4. Hypotensive effect

3. Paradoxical effect **Methylphenidate (Ritalin), a stimulant, has an opposite effect on hyperactive children; the reason for this action is as yet totally unexplained

What should the nurse do when a client with the diagnosis of schizophrenia talks about being controlled by others? 1. Express disbelief about the client's delusion 2. Divert the client's attention to unit activities 3. React to the feeling tone of the client's delusion 4. Respond to the verbal content of the client's delusion

3. React to the feeling tone of the client's delusion

One day while shaving, a male client with the diagnosis of bipolar disorder tells the nurse, "I've hidden a razor blade, and tonight I'm going to kill myself." What is the best reply by the nurse? 1. "You're going to kill yourself?" 2. "Things really can't be that bad." 3. "Are you sure you really mean that?" 4. "Killing yourself is not going to solve your problems."

1. "You're going to kill yourself?"

What is the most appropriate intervention for the nurse to implement after finding a disturbed client in bed in the fetal position? 1. Sitting down in a chair by the client and saying, "I'm here to spend time with you." 2. Touching the client gently on the shoulder and saying, "I'm going to sit with you for a while." 3. Going to the client and saying, "I'll be waiting for you in the community room, so please get up and join me." 4. Leaving the client alone because the behavior demonstrates that the client has regressed too far to benefit from talking with the nurse

1. Sitting down in a chair by the client and saying, "I'm here to spend time with you."

The nurse refers a client to a self-help group. What does the nurse anticipate that a self-help groups such as Alcoholics Anonymous (AA) will help its members learn? 1. That their problems are not unique 2. That they do not need a crutch to lean on 3. That their problems are caused by alcohol 4. That the group can stop them from drinking

1. That their problems are not unique **Sharing problems with others who have similar problems can help one explore feelings and begin to enhance coping abilities.

A nurse is monitoring a client with the diagnosis of schizophrenia who is experiencing opposing emotions simultaneously. When providing a change-of-shift report, how should the nurse refer to this emotional experience of the client? 1. Double bind 2. Ambivalence 3. Loose association 4. Inappropriate affect

2. Ambivalence

A client with a diagnosis of paranoid schizophrenia throws a chair across the room and starts screaming at the other clients. Several of these clients have frightened expressions, one starts to cry, and another begins to pace. A nurse removes the agitated client from the room. What should the nurse remaining in the room do next? 1. Continue the unit's activities as if nothing has happened 2. Arrange a unit meeting to discuss what has just happened 3. Refocus clients' negative comments to more positive topics 4. Have a private talk with the clients who cried and started to pace

2. Arrange a unit meeting to discuss what has just happened

A client is admitted with a conversion disorder. What is the primary nursing intervention? 1. Talking about the physical problems 2. Exploring ways to verbalize feelings 3. Explaining how stress caused the physical symptoms 4. Focusing on the client's concerns regarding the symptoms

2. Exploring ways to verbalize feelings

A client is admitted to the psychiatric hospital with a diagnosis of obsessive-compulsive disorder. The client's anxiety level is approaching a panic level, and the client's ritual is interfering with work and daily living. Which selective serotonin reuptake inhibitor (SSRI) should the nurse anticipate that the health care provider may prescribe? 1. Haloperidol (Haldol) 2. Fluvoxamine (Luvox) 3. Imipramine (Tofranil) 4 .Benztropine (Cogentin)

2. Fluvoxamine (Luvox) **Fluvoxamine (Luvox) inhibits central nervous system neuron uptake of serotonin but not of norepinephrine.

A nurse encourages a client to attend Alcoholics Anonymous (AA) meetings after discharge. What do self-help groups such as AA help their members do? 1. Set long-term goals 2. Limit excessive drinking 3. Foster changes in behavior 4. Identify underlying causes of behavior

3. Foster changes in behavior

A nurse concludes that a client is using displacement. Which behavior has the nurse identified? 1. Ignoring unpleasant aspects of reality 2. Resisting any demands made by others 3. Using imaginative activity to escape reality 4. Directing pent-up emotions at someone other than the primary source

4. Directing pent-up emotions at someone other than the primary source

An older female client is concerned about maintaining her independent living status. What initial intervention strategy is of primary importance? 1. Reinforcing routines and supporting her usual habits 2. Helping her secure assistance with cleaning and shopping 3. Writing down and repeating important information for her use 4. Setting clear goals and time limitations for her visits with the nurse

1. Reinforcing routines and supporting her usual habits

An executive, busy at work, receives a phone call from a friend relating bad news. The woman makes a conscious effort to put this information out of her mind and continues to work at the task at hand. The next day she remembers that her friend telephoned her but is unable to recall the message. Which defense mechanism does this behavior represent? 1. Regression 2. Suppression 3. Passive aggression 4. Reaction formation

2. Suppression **Suppression is the voluntary exclusion from awareness of anxiety-producing feelings, ideas, and situations.

After an automobile collision involving a fatality and a subsequent arrest for speeding, a client has amnesia regarding the events surrounding the accident. Which defense mechanism is being used by the client? 1. Projection 2. Repression 3. Suppression 4. Rationalization

2. Repression

The nurse should suspect that a client who had a recent myocardial infarction is experiencing denial when the client: 1. Attempts to minimize the illness 2. Lacks an emotional response to the illness 3. Refuses to discuss the condition with the client's spouse 4. Expresses displeasure with the prescribed activity program

1. Attempts to minimize the illness

What characteristic is most essential for the nurse caring for a client undergoing mental health care? 1. Empathy 2. Sympathy 3. Organization 4. Authoritarianism

1. Empathy **Empathy—understanding and to some extent sharing the emotions of another—encourages the expression of feelings. Empathy is an essential tool in caring for emotionally ill clients.

Sildenafil (Viagra) is prescribed for a man with erectile dysfunction. A nurse teaches the client about common side effects of this drug. (Select all that apply.) 1. Flushing 2. Headache 3. Dyspepsia 4. Constipation 5. Hypertension

1. Flushing 2. Headache 3. Dyspepsia

The nurse interviews a young female client with anorexia nervosa to obtain information for the nursing history. What will the client's history most likely reveal? (Select all that apply.) 1. Ritualistic behaviors 2. Desire to improve her self-image 3. Supportive mother-daughter relationship 4. Low achievement in school and little concern for grades 5. Satisfaction with and a desire to maintain her current weight

1. Ritualistic behaviors 2. Desire to improve her self-image

A 2½-year-old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. Child abuse is suspected. What statements might the nurse expect from a parent who engages in child abuse? (Select all that apply.) 1. "Kids have to learn to be careful on the stairs." 2. "Every time I turn around the kid is falling over something." 3. "He tends to be adventurous and doesn't understand about getting hurt on the stairs." 4. "I can't understand it. He didn't have a problem using the stairs without my help before this." 5. "I try to keep an eye on him, but little kids are always on the go and I just can't keep running after him."

2. "Every time I turn around the kid is falling over something." 4. "I can't understand it. He didn't have a problem using the stairs without my help before this."

An older retired client is visiting the clinic for a regularly scheduled checkup. The client tells the nurse about the great life he has lived and the activities that he enjoys at the senior center. According to Erikson, what developmental conflict has been resolved by this client? 1. Trust versus mistrust 2. Integrity versus despair 3. Generativity versus self-absorption 4. Autonomy versus shame and doubt

2. Integrity versus despair

What is an initial client objective in relation to anger management? 1. Expressing remorse over aggressive actions 2. Taking responsibility for the hostile behavior 3. Developing alternative methods to release feelings 4. Teaching others how to avoid triggering the angry behavior

2. Taking responsibility for the hostile behavior

A male college student who is smaller than average and unable to participate in sports becomes the life of the party and a stylish dresser. What defense mechanism does the nurse determine that the client is using? 1. Introjection 2. Sublimation 3. Compensation 4. Reaction formation

3. Compensation **By developing skills in one area, the individual compensates for a real or imagined deficiency in another, thereby maintaining a positive self-image.

A group of clients from a psychiatric unit, accompanied by staff members, are going to a professional baseball game. The purpose of visits into the community under the supervision of staff members is: 1. Helping clients adjust to stressors in the community 2. Helping clients return to reality under controlled conditions 3. Observing the clients' abilities to cope with a more complex society 4. Broadening the clients' experiences by providing exposure to cultural activities

3. Observing the clients' abilities to cope with a more complex society

Imipramine (Tofranil), 75 mg three times per day, is prescribed for a client. What nursing action is appropriate when this medication is being administered? 1. Telling the client that barbiturates and steroids will not be prescribed 2. Warning the client not to eat cheese, fermented products, and chicken liver 3. Monitoring the client for increased tolerance and reporting when the dosage is no longer effective 4. Having the client checked for increased intraocular pressure and teaching about symptoms of glaucoma

4. Having the client checked for increased intraocular pressure and teaching about symptoms of glaucoma **Glaucoma is one of the side effects of imipramine (Tofranil), and the client should be taught the symptoms.

A client with a history of aggressive, violent behavior is admitted to the psychiatric unit involuntarily. The nurse, who understands the need to use deescalation approaches during the preassaultive stage of the violence cycle, monitors the client's behavior closely for progression of signs of impending violence. List these client behaviors in order of escalating aggression, from the lowest risk to the highest. 1.Pacing in the hall 2.Increasing tension in facial expression 3.Engaging in verbal abuse toward the nurse 4.Pushing another client while waiting in line to the dining room 5.Having difficulty waiting to take turns during a group project

2.Increasing tension in facial expression 5.Having difficulty waiting to take turns during a group project 1.Pacing in the hall 3.Engaging in verbal abuse toward the nurse 4.Pushing another client while waiting in line to the dining room

A nurse leads an assertiveness training program for a group of clients. Which statement by a client indicates that the treatment has been effective? 1. "I know that I should put the needs of others before mine." 2. "I won't stand for it, so I told my boss he's a jerk and to get off my back." 3. "It annoys me when people call me 'sweetie,' so I told him not to do it anymore." 4. "It's easier for me to agree up front and then do just enough so that no one notices."

3. "It annoys me when people call me 'sweetie,' so I told him not to do it anymore."

What is the most difficult initial task in the development of a nurse-client relationship? 1. Remaining therapeutic and professional 2. Being able to understand and accept a client's behavior 3. Developing an awareness of self and the professional role in the relationship 4. Accepting responsibility for identifying and evaluating the real needs of a client

3. Developing an awareness of self and the professional role in the relationship **The nurse's major tool in mental health nursing is the therapeutic use of self. Mental health nurses must learn to identify their own feelings and understand how they affect the situation.

A nurse is caring for several clients who have severe psychiatric disorders. What is the major reason that a health care provider prescribes an antipsychotic medication for these clients? 1. To improve judgment 2. To promote social skills 3. To diminish neurotic behavior 4. To reduce the positive symptoms of psychosis

4. To reduce the positive symptoms of psychosis **Antipsychotics are used to decrease positive signs and symptoms associated with psychoses, including hallucinations, delusions, paranoia, and disorganized speech.

A client is to begin lithium carbonate therapy. The nurse should ensure that before the drug's administration the client has baseline: 1. Renal studies 2. Liver enzyme studies 3. Adrenal function studies 4. Pulmonary function studies 5. New Choice 6. New Choice 7. New Choice

1. Renal studies

An adult who has been in a gay relationship for 3 years arrives at the emergency department in a state of near-panic. The client says, "My partner just left me. I'm a wreck." What should the nurse do to help the client cope with this loss? (Select all that apply.) 1. Identify the client's support systems 2. Explore the client's psychotic thoughts 3. Reinforce the client's current self-image 4. Encourage the client to talk about the situation 5 . Suggest that the client explore personal sexual attitudes

1. Identify the client's support systems 4. Encourage the client to talk about the situation

A college student is brought to the mental health clinic by his parents. The diagnosis is borderline personality disorder. Which factors in the client's history support this diagnosis? (Select all that apply.) 1. Impulsiveness 2. Lability of mood 3. Ritualistic behavior 4. Psychomotor retardation 5. Self-destructive behavior

1. Impulsiveness 2. Lability of mood 5. Self-destructive behavior

A client who had to be cut out of a car after a motor vehicle collision has no visible physical effects from the ordeal. The client responds to the emergency department nurse's questions factually in a soft voice with a composed manner. This behavior may indicate that the client: 1. Is controlling the expression of feelings 2. Has repressed the details of the accident 3. Has blocked out the events of the last few hours 4. Is experiencing the reorganization phase of the trauma experience

1. Is controlling the expression of feelings

A 17-year-old client is admitted to the hospital because of weight loss and malnutrition, and the health care provider diagnoses anorexia nervosa. After the client's physical condition is stabilized, the provider, in conjunction with the client and parents, decides to institute a behavior-modification program. What component of behavior modification verbalized by one of the parents leads the nurse to conclude that the parent has an understanding of the therapy? 1. Rewarding positive behavior 2. Deconditioning fear of weight gain 3. Decreasing unnecessary restrictions 4. Reducing anxiety-producing situations

1. Rewarding positive behavior

What is the basic therapeutic tool used by the nurse to foster a client's psychological coping? 1. Self 2. Milieu 3. Helping process 4. Client's intellect

1. Self

Oral chlordiazepoxide (Librium) 100 mg/ hr is prescribed for a client with a Clinical Institute Withdrawal Assessment (CIWA) score of 25. The client has had 300 mg in 3 hours but is still displaying acute alcohol withdrawal symptoms. What is the next nursing action? 1. Informing the client that the limit of chlordiazepoxide has been reached 2. Administering chlordiazepoxide as indicated by the client's CIWA score 3. Requesting a prescription for another medication to replace the chlordiazepoxide. 4. Informing the health care provider that the maximum dose of chlordiazepoxide has been reached

2. Administering chlordiazepoxide as indicated by the client's CIWA score **Medication of clients in acute withdrawal from alcohol should be based on withdrawal symptoms, not medication dosage.

A 23-year-old woman is admitted to a psychiatric unit after several episodes of uncontrolled rage at her parents' home, and borderline personality disorder is diagnosed. While watching a television newscast describing an incident of violence in the home, the client says, "People like that need to be put away before they kill someone." The nurse concludes that the client is using: 1. Denial 2. Projection 3. Introjection 4. Sublimation

2. Projection **Projection is the process of attributing one's thoughts about one's self to others.

A health care provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior. What is the nurse's responsibility in regard to this order? 1. Asking that the order indicate the type of restraint 2. Recognizing that PRN orders for restraints are unacceptable 3. Implementing the restraint order when the client begins to act out 4. Ensuring that the entire staff is aware of the order for the restraints

2. Recognizing that PRN orders for restraints are unacceptable

An older client whose family has been visiting on the psychiatric unit is visibly angry and says to the nurse, "My daughter-in-law says they can't take me home until the doctor lets me go. She doesn't understand how important this is to me; she's not from our culture." What should the nurse do? 1. Ignore the statement for the present 2. Say, "You feel she doesn't want you at home. 3. Reflect on the client's feelings about the cultural differences 4. Respond, "The doctor is the one who makes decisions about discharge."

2. Say, "You feel she doesn't want you at home.

A client is admitted for treatment of obsessive-compulsive disorder that is interfering with activities of daily living. Which medication should the nurse anticipate the health care provider will prescribe? 1. Benztropine (Cogentin) 2. Amantadine (Symmetrel) 3. Clomipramine (Anafranil) 4. Diphenhydramine (Benadryl)

3. Clomipramine (Anafranil)

A client with schizophrenia is started on an antipsychotic/neuroleptic medication. The nurse explains to a family member that this drug primarily is used to: 1. Keep the client quiet and relaxed 2. Control the client's behavior and reduce stress 3. Reduce the client's need for physical restraints 4. Make the client more receptive to psychotherapy

4. Make the client more receptive to psychotherapy

The nurse is explaining the Client Bill of Rights to a female client whose psychiatrist has admitted her to an inpatient facility. Her admission is voluntary. The statement that is not a client right is the right to: 1. Personal mail 2. Refuse treatment 3. Written treatment plans 4. Select health team members

4. Select health team members **Clients may not select the members of the health care team when admitted to an inpatient setting that delivers care 24 hours a day, 7 days a week. The other rights are included in the Client Bill of Rights.

A primary nurse notes that a client has become jaundiced after 2 weeks of antipsychotic drug therapy. The nurse continues to administer the antipsychotic until the health care provider can be consulted. What does the nurse manager conclude about this situation? 1. Jaundice is sufficient reason to discontinue the antipsychotic. 2. Jaundice is a benign side effect of antipsychotic agents that has little significance. 3. The blood level of an antipsychotic drug must be maintained once it has been established. 4 .The prescribed dosage for the antipsychotic agent should have been reduced by the nurse.

1. Jaundice is sufficient reason to discontinue the antipsychotic.

A client with the diagnosis of schizophrenia, paranoid type, has been receiving a phenothiazine drug. The daycare center is planning a fishing trip. It is important that the nurse: 1. Provide the client with sunscreen 2. Caution the client to limit exertion during the trip 3. Give the client an extra dose of medication to take after lunch 4. Take the client's blood pressure before allowing him to participate in the outing

1. Provide the client with sunscreen

A client begins fighting and biting other clients. The practitioner prescribes a stat injection of haloperidol (Haldol). How should the nurse implement this prescription? 1. Quickly, with an attitude of concern 2. Before the client realizes what is happening 3. After the client agrees to receive the injection 4. Quietly, without any explanation of the reason for it

1. Quickly, with an attitude of concern **Quickness is used for safety; an attitude of concern may help reduce the client's anxiety.

What should a nurse ensure when creating an environment that is conducive to psychological safety? 1. Realistic limits are set. 2. Passive acceptance is promoted. 3. The client's physical needs are met. 4. The physical environment is kept in order

1. Realistic limits are set.

What is the most important information for a nurse to teach to prevent relapse in a client with a psychiatric illness? 1. The need to develop a close support system 2. The need to create a stress-free environment 3. The need to refrain from activities that cause anxiety 4. The need to follow the prescribed medication regimen

4. The need to follow the prescribed medication regimen

The nurse anticipates that the medication that will be used to prevent symptoms of withdrawal in clients with a long history of alcohol abuse is: 1. Lorazepam (Ativan) 2. Phenobarbital (Luminal) 3. Chlorpromazine (Thorazine) 4. Methadone hydrochloride (Methadone)

1. Lorazepam (Ativan) **Lorazepam (Ativan) is most effective in preventing the signs and symptoms associated with withdrawal from alcohol.

Which nursing intervention involves providing, structuring, and maintaining a safe and therapeutic environment in collaboration with patients, families, and other health care providers? 1. Milieu therapy 2. Coordination of care 3. Health teaching and health maintenance 4. Pharmacologic, biologic, and integrative therapies

1. Milieu therapy **Milieu therapy involves providing, structuring, and maintaining a safe and therapeutic environment in collaboration with psychiatric patients, families, and other health care providers.

A nurse is caring for an adolescent who has anorexia nervosa. The nutritional treatment of anorexia is composed of several guidelines. Which guidelines should the nurse emphasize? (Select all that apply.) 1. Increasing high-fiber foods 2. Eating just three meals a day 3. Increasing food intake gradually 4. Limiting mealtime to half an hour 5. Providing privileges for goal achievement

3. Increasing food intake gradually 4. Limiting mealtime to half an hour 5. Providing privileges for goal achievement

A woman who is frequently physically abused tells the nurse in the emergency department that it is her fault that her husband beats her. What is the most therapeutic response by the nurse? 1. "Maybe it was your husband's fault, too." 2. "I can't agree with that—no one should be beaten." 3. "Tell me why you believe that you deserve to be beaten." 4. "You say that it was your fault—help me understand that."

4. "You say that it was your fault—help me understand that."

A nurse is teaching a client about side effects of medications. Which drug will cause a heightened skin reaction to sunlight? 1. Lithium 2. Sertraline 3. Methylphenidate 4. Chlorpromazine

4. Chlorpromazine

One afternoon a nurse sees a client rushing down the hall of the mental health unit, rapidly tapping his fingers against the wall. What is the most appropriate nursing action at this time? 1. Approaching the client in a nonthreatening manner to determine the cause of the agitation 2. Summoning additional staff members to forcefully subdue the client and stop the acting-out behavior 3. Observing the client to see whether the behavior escalates and whether it may pose a risk to other clients or staff 4. Immediately obtaining staff assistance to enable administration of medication prescribed for the client's agitation

1. Approaching the client in a nonthreatening manner to determine the cause of the agitation

On the psychiatric unit a client has been receiving high doses of haloperidol (Haldol) for 2 weeks. The client says, "I just can't sit still, and I feel jittery." Which side effect does the nurse suspect that the client is experiencing? 1. Akathisia 2. Torticollis 3. Tardive dyskinesia 4. Parkinsonian syndrome

1. Akathisia **Akathisia, a side effect of haloperidol (Haldol), develops early in therapy and is characterized by restlessness and agitation.

A parent of four is remanded to the psychiatric unit by the court for observation. The client was arrested and charged with abusing a 2-year-old son, who is in the pediatric intensive care unit in critical condition. The nurse approaches the client for the first time. How should the nurse anticipate that the client will likely respond? (Select all that apply.) 1. By denying beating the son 2. By avoiding talking about the situation 3. By expressing excessive concern for the son 4. By asking where the other three children are 5. Emotional response is inconsistent with degree of injury

1. By denying beating the son 2. By avoiding talking about the situation 5. Emotional response is inconsistent with degree of injury

A client is receiving doxepin (Sinequan). For which most dangerous side effect of tricyclic antidepressants should a nurse monitor the client? 1. Mydriasis 2. Dry mouth 3. Constipation 4. Urine retention

1. Mydriasis

Before a treatment requiring informed consent can be performed, what information must the client be given? (Select all that apply.) 1. The cost of the treatment 2. Alternative treatment options 3. The risks and benefits of the treatment 4.The risks involved in refusing the treatment 5. The nature of the problem requiring the treatment

2. Alternative treatment options 3. The risks and benefits of the treatment 4.The risks involved in refusing the treatment 5. The nature of the problem requiring the treatment

When talking with a client who has alcoholism, the nurse notes that the client becomes irritable, makes excuses, and blames family and friends for the drinking problem. Which defense mechanisms does the nurse conclude that the client is using? (Select all that apply.) 1. Projection 2. Suppression 3. Sublimation 4. Identification 5. Rationalization

1. Projection 5. Rationalization **Projection is the unconscious denial of unacceptable feelings and emotions in one's self while attributing them to others. This defense mechanism commonly is used by clients with alcoholism because it helps make reality more acceptable. Rationalization is making acceptable excuses for behavior; this defense is used by people with alcoholism because it makes reality more acceptable.

Antipsychotic drugs can cause extrapyramidal side effects. Which responses should the nurse document as indicating pseudoparkinsonism? (Select all that apply.) 1. Rigidity 2. Tremors 3. Mydriasis 4. Photophobia 5. Bradykinesia

1. Rigidity 2. Tremors 5. Bradykinesia

A nurse teaches dietary guidelines to a client who will be receiving tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor (MAOI). The client compiles a list of foods to avoid. Which foods included on the list indicate that the teaching has been effective? (Select all that apply.) 1. French fries 2. Pepperoni pizza 3. Bologna sandwich 4 . Hamburger on a bun 5 . Hash brown potatoes

2. Pepperoni pizza 3. Bologna sandwich

Neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. What signs and symptoms of this syndrome should the nurse identify? (Select all that apply.) 1. Jaundice 2. Diaphoresis 3. Hyperrigidity 4. Hyperthermia 5. Photosensitivity

2. Diaphoresis 3. Hyperrigidity 4. Hyperthermia **Diaphoresis, hyperrigidity, and hyperthermia occur with neuroleptic malignant syndrome as a result of dopamine blockade in the hypothalamus.

A hospitalized 7-year-old boy wakes up crying because he has wet his bed. It is most appropriate for the nurse to: 1. Allow the child to change his bed and pajamas 2. Change the child's bed while he changes his pajamas 3. Take the child to the bathroom and change his pajamas 4. Remind the child to call the nurse next time to avoid the need to change his pajamas

2. Change the child's bed while he changes his pajamas **Changing the child's bed while the child changes his pajamas will not call attention to the accident and will minimize the child's embarrassment.

A recently married 22-year-old woman is brought to the trauma center by the police. She has been robbed, beaten, and sexually assaulted. The client, although anxious and tearful, appears to be in control. The health care provider prescribes alprazolam (Xanax) 0.25 mg for agitation. The nurse should administer this medication when the: 1. Client's crying increases 2. Client requests something to calm her 3. Nurse determines a need to reduce her anxiety 4. Health care provider is getting ready to perform a vaginal examination

2. Client requests something to calm her **Because a sexual assault is a threat to the sense of control over one's life, some control should be given back to the client as soon as possible.

A client has been prescribed chlorpromazine (Thorazine) for the management of positive symptoms of schizophrenia. When the client reports difficulty sustaining an erection, the nurse: 1. Reassures him this side effect will resolve in a few weeks 2. Consults with his provider regarding alternative medication therapies 3. Explains that all conventional antipsychotic medications cause impotence 4. Provides additional medication education to explain the medication's side effects in detail

2. Consults with his provider regarding alternative medication therapies

An injured child is brought to the emergency department by the parents. While interviewing the parents, the nurse begins to suspect child abuse. Which parental behaviors might support this conclusion? (Select all that apply.) 1. Demonstrating concern for the injured child 2. Focusing on the child's role in sustaining the injury 3. Changing the story of how the child sustained the injury 4. Asking questions about the injury and the child's prognosis 5. Giving an explanation of how the injury occurred that is not consistent with the injury

2. Focusing on the child's role in sustaining the injury 3. Changing the story of how the child sustained the injury 5. Giving an explanation of how the injury occurred that is not consistent with the injury

A nurse in the mental health clinic concludes that a client is using confabulation when: 1. The flow of thoughts is interrupted 2. Imagination is used to fill in memory gaps 3. Speech flits from one topic to another with no apparent meaning 4. Connections between statements are so loose that only the speaker understands them

2. Imagination is used to fill in memory gaps **Using imagination to fill in memory gaps is the definition of confabulation; it is a defense mechanism used by people experiencing memory deficits.

When a newly admitted client with paranoid ideation tells the nurse about people coming through the doors to commit murder, the nurse should: 1. Ignore the client's stories 2. Listen to what the client is saying 3. Explain that no one can get through the door 4. Ask for an explanation of where the information was obtained

2. Listen to what the client is saying

A nurse notes that haloperidol (Haldol) is most effective for clients who exhibit behavior that is: 1. Depressed 2. Overactive 3. Withdrawn 4. Manipulative

2. Overactive

A client who is being treated in a mental health clinic is to be discharged after several months of therapy. The client anxiously tells the nurse, "I don't know what I'll do when I can't see you anymore." The nurse determines that the client is: 1. Expressing thanks to the nurse 2. Reacting to the planned discharge 3. Attempting to manipulate the nurse 4. Indicating a need for further treatment

2. Reacting to the planned discharge

The emergency department nurse is conducting an interview and assisting with the physical examination of a female sexual assault victim. What is most important for the nurse to document on this client's record? 1. Observations about the client's reaction to male staff members 2. Statements by the client about the sexual assault and the rapist 3. Information about the client's previous knowledge of the rapist 4. Summary statement about the client's description of the assault and the rapist

2. Statements by the client about the sexual assault and the rapist

In response to a question posed during a group meeting, the nurse explains that the superego is that part of the self that says: 1. "I like what I want." 2. "I want what I want." 3. "I shouldn't want that." 4. "I can wait for what I want."

3. "I shouldn't want that." **Conscience and a sense of right and wrong are expressed in the superego, which acts to counterbalance the id's desire for immediate gratification.

A family member brings a relative to the local community hospital because the relative "has been acting strange." Which statements meet involuntary hospitalization criteria? (Select all that apply.) 1. "I cry all the time; I'm just so sad." 2 . "Since I retired I've been so depressed." 3. "I'd like to end it all with sleeping pills." 4 . "The voices say I should kill all prostitutes." 5 . "My boss makes me so angry—he's always picking on me."

3. "I'd like to end it all with sleeping pills." 4 . "The voices say I should kill all prostitutes." **Rationale: The statement about ending it all is a suicide threat; it is a direct expression of intent without action. Likewise, the threat to harm others must be heeded.

In conjunction with which classification of medication are trihexyphenidyl, biperiden (Akineton), and benztropine (Cogentin) often prescribed? 1. Anxiolytics 2. Barbiturates 3. Antipsychotics 4. Antidepressants

3. Antipsychotics

What is the most therapeutic nursing intervention to help a late-middle-aged individual cope with the emotional aspects of aging? 1. Focusing on the individual's past experiences 2. Having the individual attend lectures on aging 3. Assisting the individual with plans for the future 4. Encouraging the individual to focus on his or her career

3. Assisting the individual with plans for the future **Helping an individual maintain an interest in the future is therapeutic. It is forward looking and fosters a positive attitude.

As the nurse is discussing psychiatric care with an older adult client, the client says, "When I was growing up I was taught to accept my lot in life and not complain. I'm proud of the fact that despite my issues I can still function independently. I don't want to be just put away." The nurse understands that the factors that influence the client's mental health are examples of: 1. Setting of care 2. Anxiety disorder 3. Attitudes and beliefs 4. Cultural and ethnic disparities

3. Attitudes and beliefs

A parent whose daughter is killed in a school bus accident tearfully tells the nurse, "My daughter was just getting over the chickenpox and didn't want to go to school, but I insisted that she go. It's my fault that she's dead." How should the nurse anticipate that perceiving a death as preventable will likely influence the grieving process? 1. The loss may be easier to understand and accept. 2. The mourner may experience pathological grief. 3. Bereavement may be of greater intensity and duration. 4. The grieving process may progress to a psychiatric illness

3. Bereavement may be of greater intensity and duration.

On the first day of the month a practitioner prescribes an antipsychotic medication for a client with schizophrenia. The initial dosage is 25 mg once a day, to be titrated in increments of 25 mg every other day to a desired dosage of 175 mg daily. On what day of the month will the client reach the desired daily dose of 175 mg? 1. Day 7 2. Day 9 3. Day 13 4. Day 15

3. Day 13 **The client will reach the desired dosage of 175 mg on the 13th day of the month; on the first day it is 25 mg, on the third day it is 50 mg, on the fifth day it is 75 mg, on the seventh day it is 100 mg, on the ninth day it is 125 mg, on the 11th day it is 150 mg, and on the 13th day it is 175 mg.

A health care provider refers a 52-year-old man to the mental health clinic. The history reveals that the man lost his wife to colon cancer 6 months ago and that since that time he has seen his health care provider seven times with the concern that he has colon cancer. All tests have had negative results. Recently the client stopped seeing friends, dropped his hobbies, and stayed home to rest. Which disorder should the nurse identify as consistent with the client's preoccupation with the fear of having a serious disease? 1. Conversion disorder 2. Somatization disorder 3. Hypochondriac disorder 4. Body dysmorphic disorder

3. Hypochondriac disorder **Preoccupation with fears of getting or having a serious disease is called hypochondriasis

A client in the mental health clinic who has been seeing a therapist for more than 6 months begins to talk and act like a therapist who is analyzing coworkers. What defense mechanism does the nurse identify? 1. Undoing 2. Projection 3. Introjection 4. Intellectualization

3. Introjection **Introjection is treating something outside the self as if it is actually inside the self; it is unconsciously incorporating the wishes, values, and attitudes of another as if they were one's own.

A client with schizophrenia who has type II (negative) symptoms is prescribed risperidone (Risperdal). Which outcomes indicate that the medication has minimized these symptoms? (Select all that apply.) 1.There is less agitation. 2.There are fewer delusions. 3. More interest is shown in unit activities. 4. The client reports that the hallucinations have stopped. 5. The client performs activities of daily living independently.

3. More interest is shown in unit activities. 5. The client performs activities of daily living independently.

Which tool is used to standardize and measure nursing treatments? 1. Nursing Outcomes Classification (NOC) 2. NANDA-I-Approved Nursing Diagnoses 3. Nursing Interventions Classification (NIC) 4. Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

3. Nursing Interventions Classification (NIC) **Nursing Interventions Classification (NIC) is a tool that helps to define nursing interventions, as well as helps to standardize and measure the nursing care provided.

A client has been prescribed lithium. What important nursing intervention must be implemented while this medication is being administered? 1. Restricting the client's daily sodium intake 2. Testing the client's urine specific gravity weekly 3. Regularly testing the level of the drug in the client's blood 4. Withholding the client's other medications for several days

3. Regularly testing the level of the drug in the client's blood

A 19 year-old, arrested for assault and robbery, has a history of truancy and prostitution but is unconcerned that her behavior has caused emotional distress to others. The diagnosis of antisocial personality disorder is made. According to psychoanalytical theory, the client's lack of remorse and repetitive behavior probably are related to an underdeveloped: 1. Id 2. Ego 3. Superego 4. Limbic system

3. Superego

A client with depression is to be given fluoxetine (Prozac). What precaution should the nurse consider when initiating treatment with this drug? 1. It must be given with milk and crackers to avoid hyperacidity and discomfort. 2. Eating cheese or pickled herring or drinking wine may cause a hypertensive crisis. 3. The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks. 4. The blood level should be checked weekly for 3 months to monitor for an appropriate level.

3. The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks. **Fluoxetine (Prozac) does not produce an immediate effect; nursing measures must be continued to reduce the risk for suicide

A client with generalized anxiety disorder says to the nurse, "What can I do to keep myself from overreacting to stress?" What is the best response by the nurse? 1. "Work on problem-solving skills." 2. "Improve your time-management skills." 3. "Ignore situations that you cannot change." 4. "Work on identifying and developing coping strategies."

4. "Work on identifying and developing coping strategies."

A nurse determines that confrontation is an appropriate tool for use with a client. What is an example of therapeutic confrontation? 1. "I find that hard to believe." 2. "I noticed that you're not wearing any makeup today." 3. "You feel frustrated because you think your mother doesn't understand you." 4. "You say you're not a good parent, but you were effective when you were talking with your son today."

4. "You say you're not a good parent, but you were effective when you were talking with your son today."

An older man is widowed suddenly when his wife is killed in an automobile accident. What should the nurse in the emergency department do first to best help the client at this time? 1. Ask a member of the clergy to visit him 2. Have the practitioner prescribe a sedative for him 3. Refer him to a support group that meets near his home 4. Assure him that everything possible was done for his wife

4. Assure him that everything possible was done for his wife

Thirty minutes after administering fluphenazine (Prolixin) to a client, the nurse notes that the client's jaw is rigid, the client is drooling, and her speech is slurred. There are a number of as-needed prescriptions in the client's chart. What should the nurse administer? 1. Diazepam (Valium), 10 mg by mouth 2. Trihexyphenidyl (Artane), 1 mg by mouth 3. Haloperidol (Haldol), 2 mg intramuscularly 4. Benztropine (Cogentin), 2 mg intramuscularly7

4. Benztropine (Cogentin), 2 mg intramuscularly7 **Benztropine (Cogentin) is an anticholinergic, antiparkinsonian drug used to treat drug-induced extrapyramidal symptoms associated with phenothiazine therapy; the intramuscular (IM) route will relieve symptoms more rapidly.

A female nurse has been caring for a depressed 75-year-old woman who reminds her of her grandmother. The nurse spends extra time with her every day and brings her home-baked cookies. The nurse's behavior reflects: 1. Affiliation 2. Displacement 3. Compensation 4. Countertransference

4. Countertransference **With countertransference the professional provider of care exhibits an emotional reaction to a client based on a previous relationship or on unconscious needs or conflicts.

In the process of development the individual strives to maintain, protect, and enhance the integrity of the self. The nurse determines that this is usually accomplished through the use of: 1. Affective reactions 2. Withdrawal patterns 3. Ritualistic behaviors 4. Defense mechanisms

4. Defense mechanisms **When the individual experiences a threat to self-esteem, anxiety increases, and defense mechanisms are used to protect the self

A client with a diagnosis of schizophrenia is discharged from the hospital. At home the client forgets to take the medication, is unable to function, and must be rehospitalized. What medication may be prescribed that can be administered on an outpatient basis every 2 to 3 weeks? 1. Lithium 2. Diazepam 3. Fluvoxamine 4. Fluphenazine

4. Fluphenazine **Fluphenazine can be given intramuscularly every 2 to 3 weeks to clients who are unreliable about taking oral medications; it allows them to live in the community while keeping the disorder under control.

The husband of a woman who gave birth to a baby 2 weeks ago calls the postpartum unit at the hospital, seeking assistance for his wife. He reports that he found his wife in bed and that the baby was wet, dirty, and crying in the crib. He says, "She says she just can't do it." What is the best response by the nurse? 1. Encouraging him to express his feelings about the situation 2. Telling him to schedule an appointment with the gynecologist 3. Asking whether he can afford a home health aide for several weeks 4. Informing him that he should seek emergency intervention for his wife

4. Informing him that he should seek emergency intervention for his wife **The inability to care for herself or her infant is a significant sign that the wife is depressed and in need of immediate intervention

A young female client admitted to the trauma center after being sexually assaulted continues to talk about the rape. Toward what goal should the primary nursing intervention be directed? 1. Getting her involved with a rape therapy group 2. Remaining available and supportive to limit destructive anger 3. Exploring her feelings about men to promote future relationships 4. Providing a safe environment that permits the ventilation of feelings

4. Providing a safe environment that permits the ventilation of feelings

A client on the psychiatric unit who has suicidal ideas says to the nurse, "I signed myself in. I'll sign myself out." What concept provides the basis for the nurse's response? 1. Voluntary clients may sign out at any time. 2. Voluntary clients may sign out by following unit procedures. 3. Suicidal clients may sign out if they are able to contract for their safety. 4. Suicidal clients may not sign out even if they voluntarily admitted themselves.

4. Suicidal clients may not sign out even if they voluntarily admitted themselves. **The priority is to keep the client safe; a client admitted on a voluntary basis may be kept involuntarily if professional judgment indicates that the client may harm him- or herself or others.

A health care provider prescribes haloperidol (Haldol) for a client. What should the nurse teach the client to avoid while taking this medication? 1. Driving at night 2. Staying in the sun 3. Ingesting aged cheeses 4. Taking medications containing aspirin

2. Staying in the sun **Haloperidol (Haldol) causes photosensitivity. Severe sunburn may occur on exposure to the sun.