Foundations of Psychiatric Nursing SCC 4th quarter psych

The nurse is teaching an unlicensed assistive personnel (UAP) about the care of clients with self-mutilation. Which statement by the UAP would indicate teaching about self-mutilation has been effective? a) "It is a means of getting what the person wants." b) "It is a form of manipulation." c) "It is a nonserious event that can be ignored." d) "It is a way to express anger and rage."

"It is a way to express anger and rage."

A client asks a nurse, "Do you think I should leave my husband?" The nurse responds, "You aren't sure if you should leave your husband?" The nurse is using which therapeutic technique? a) Restating b) Offering a general lead c) Reflecting d) Reframing

Reflecting

The client has tearfully described her negative feelings about herself to the nurse during their last three interactions. Which goal would be most appropriate for the nurse to include in the plan of care at this time? The client will: a) write her negative feelings in a daily journal b) verbalize three things she likes about herself c) increase her self-esteem d) verbalize her work-related accomplishments

verbalize three things she likes about herself

The nurse is admitting a client with Borderline Personality Disorder. When planning care for this client, the nurse should give priority to which item? a) Empathy b) Safety c) Splitting d) Manipulation

Safety

In closed or locked units, the nurse judges the milieu as therapeutic when priorities are given to: a) communication, social, and leisure skills. b) recreation and vocation counseling. c) safety, structure, and support. d) socialization and self-understanding.

safety, structure, and support

The nurse is planning care for a client in restraints. Which nursing intervention is most important when restraining a this client? a) Checking that the restraints have been applied correctly b) Preparing an as-needed dose of the client's psychotropic medication c) Reviewing facility policy regarding how long the client may be restrained d) Asking if the client needs to use the bathroom or is thirsty

Checking that the restraints have been applied correctly

The stigma related to having a mental illness, especially a chronic illness, persists despite improvements in the management of illnesses and an increase in public education. Which view most perpetuates the stigma? a) Mental illness is hereditary. b) Mental illnesses have biochemical bases. c) Clients cannot prevent mental illness if they want to do so. d) Clients can recover from mental illness if they have willpower.

Clients can recover from mental illness if they have willpower.

When developing the plan of care for a client with acute stress disorder who lost her sister in a boating accident, which intervention should the nurse initiate? a) facilitating progressive review of the accident and its consequences b) helping the client to evaluate her sister's behavior c) telling the client to avoid details of the accident d) postponing discussion of the accident until the client brings it up

facilitating progressive review of the accident and its consequences

The nurse at a substance abuse center answers the phone. A probation officer asks if a client is in treatment. The nurse responds, "No, the client you're looking for isn't here." Which statement best describes the nurse's response? a) A breach of the principle of veracity because the nurse is misleading the officer b) A violation of confidentiality because she informed the officer that the client wasn't there c) Illegal, because she's withholding information from law enforcement agents d) Correct, because she didn't give out information about the client

A violation of confidentiality because she informed the officer that the client wasn't there

The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have on the client's functioning in the hospital? a) Decrease the client's feelings of isolation and loneliness. b) Keep the client from participating in therapeutic activities. c) Increase the client's confusion and disorientation. d) Cause the client to become sad

Decrease the client's feelings of isolation and loneliness.

A client becomes angry and belligerent toward the nurse after speaking on the phone with his mother. The nurse recognizes this as what defense mechanism? a) Repression b) Displacement c) Suppression d) Rationalization

Displacement

A client suddenly behaves in an impulsive, hyperactive, unpredictable manner. Which approach would be best for the nurse to use first if the client becomes violent? a) Let the client know that her behavior is not acceptable. b) Get help to handle the situation safely. c) Provide a physical outlet for the client's energies. d) Use sedation to keep the client calm

Get help to handle the situation safely.

Parents tell a nurse that they have not met their goal of home management of their son with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make? a) Evaluate the client for voluntary admission to a mental health facility. b) Discuss what the family can do to chemically restrain the client at home. c) Arrange for respite care; family members could be aggravating the client's condition. d) Tell the parents that the client's behavior releases them from the duty of care.

Evaluate the client for voluntary admission to a mental health facility.

When planning care for a client with schizophrenia, who lacks motivation to shower and dress, which outcome should the nurse expect the client to achieve by the end of 4 days? a) Recognize the need to shower and dress herself. b) Perform showering and dressing for herself. c) Verbalize the need to shower and dress herself. d) Explain reasons for showering and dressing herself.

Perform showering and dressing for herself.

A 26-year-old is being treated for delirium due to acute alcohol intoxication. The client is restless, does not want to stay seated, and has a staggering gait. What should the nurse do first? a) Provide one-to-one supervision of the client until detoxification treatment can begin. b) Ask the client to sit in a chair next to the nurses' station. c) Place the client in a chair with a waist restraint. d) Decrease stimuli by putting the client in bed with the room door closed.

Provide one-to-one supervision of the client until detoxification treatment can begin.

Which action demonstrates the role of the psychiatric nurse in primary prevention? a) Providing sexual education classes for adolescents b) Handling crisis intervention in an outpatient setting c) Conducting a postdischarge support group d) Visiting a client's home to discuss medication management

Providing sexual education classes for adolescents

Assessment of a client who has just been admitted to the inpatient psychiatric unit reveals an unshaven face, noticeable body odor, visible spots on the shirt and pants, slow movements, gazing at the floor, and a flat affect. Which of the following should the nurse interpret as indicating psychomotor retardation? a) Flat affect. b) Slow movements. c) Avoidance of eye contact. d) Unkempt appearance.

Slow movements.

When a client is about to lose control, the extra staff who come to help commonly stay at a distance from the client unless asked to move closer by the nurse who is talking to the client. What best explains the primary rationale for staying at a distance initially? a) The client is likely to perceive others as being closer than they are and feel threatened. b) The client is more likely to act out if there is an audience, even additional staff. c) When the extra staff is visible, the client is less likely to regain self-control. d) The nurse talking to the client makes the decisions about other staff actions.

The client is likely to perceive others as being closer than they are and feel threatened.

A nurse working at an outpatient mental health center primarily with chronically mentally ill clients receives a telephone call from the mother of a client who lives at home. The mother reports that the client has not been taking her medication and now is refusing to go to the work center where she has worked for the past year. What should the nurse do first? a) Make an appointment for the client to see the health care provider (HCP). b) Ask to speak to the client directly on the phone. c) Call the director of the work center for information about the client. d) Reserve an inpatient bed in preparation for the client's admission.

The client makes an effort to describe his or her problems in detail.

What should be charted by the nurse when the client has an involuntary commitment or formal admission status? a) The name of the physician officially signing the certificates should be charted. b) The client's receipt of information about status and rights should be charted. c) The client's willingness to cooperate with seclusion should be charted. d) Nothing should be charted. The forms are in the chart; there is no need to duplicate.

The client's receipt of information about status and rights should be charted.

Despite education and role-play practice of restraint procedures, a staff member is injured when actually restraining a client. When helping the uninjured staff deal with the incident, the nurse should address which factor? a) Legal action against the client will take time and energy. b) The emotional responses may be similar to those of other crime victims. c) The member is likely to resign after experiencing such an injury. d) The member must debrief with the assaultive client before returning.

The member must debrief with the assaultive client before returning.

A successful real estate agent brought to the clinic after being arrested for harassing and stalking his ex-wife denies any other symptoms or problems except anger about being arrested. The ex-wife reports to the police, "He is fine except for this irrational belief that we will remarry." When collaborating with the health care provider (HCP) about a plan of care, which intervention would be most effective for the client at this time? a) a prescription for olanzapine 10 mg daily b) referral to an outpatient therapist c) a joint session with the client and his ex-wife d) a prescription for fluoxetine 20 mg every morning

referral to an outpatient therapist

Nursing care for a client after electroconvulsive therapy (ECT) should include: a) bed rest for the first 8 hours after a treatment. b) no special care. c) assessment of short-term memory loss. d) nothing by mouth for 24 hours after the treatment because of the anesthetic agent.

assessment of short-term memory loss.

A client asks the nurse to help make out a will. The nurse should tell the client: a) "You have a long way to go before you will need to do that. Let us wait on it a while, shall we?" b) "I am not a lawyer, but I will do what I can for you." c) "You need to consult an attorney because I am not trained in such matters. Is there a family lawyer you can call?" d) "I do not believe in getting involved in legal matters, but maybe I can find another nurse who will help you."

You need to consult an attorney because I am not trained in such matters. Is there a family lawyer you can call?"

Which approach by the nurse would most likely foster a therapeutic relationship with a client who tries to manipulate people? a) strictness b) aloofness c) consistency d) sympathy

consistency

What does the nurse recognize as the primary goal of milieu management? a) implementation of healthcare providers' prescriptions b) facilitation of clients' growth, rehabilitation, and health restoration c) successful achievement of the needs of staff members d) provision of a sanctuary for helpless clients

facilitation of clients' growth, rehabilitation, and health restoration

When assessing an aggressive client, which behavior warrants the nurse's prompt reporting and use of safety precautions? a) crying when talking about his divorce b) starting a petition to delay bedtime c) declining attendance at a daily group therapy session d) naming another client as his adversary

naming another client as his adversary

The most common reason given by mentally ill clients for noncompliance with medications is their uncomfortable adverse effects. When teaching the families, what need should the nurse identify as the greatest? a) home visits to set up a week's supply of medications b) outpatient monitoring of medication compliance c) family monitoring of the administration of medication d) alternative ways to manage the adverse effects

alternative ways to manage the adverse effects

Which probe should the nurse use to encourage client evaluation of his or her own behavior? a) "What did you do differently with your coworker this time?" b) "I can hear that it is still hard for you to talk about this." c) "What will it take to carry out your new plans?" d) "So what does this all mean to you now?"

"What did you do differently with your coworker this time?"

A 35-year-old man was experiencing martial discord with his wife of 4 years. When his wife walked out, he became angry, throwing things and breaking dishes. A friend talked him into seeking help at the local mental health center. Which question should the nurse ask initially to begin to assess this man's immediate problem? a) "In hindsight, how might you have managed this situation differently?" b) "What did you do to cause your wife to leave?" c) "What led you to come in for help today?" d) "Do you feel in control of yourself at this time?"

"What led you to come in for help today?"

As the nurse stands near the window in the client's room, the client shouts, "Come away from the window! They will see you!" Which response by the nurse would be best? a) "What will happen if they do see me?" b) "Who are 'they'?" c) "You have no reason to be afraid." d) "No one will see me."

"Who are 'they'?"

A client stalks a man she met briefly 3 years earlier. She believes he loves her and eventually will marry her and she has been sending him cards and gifts. When she violates a restraining order he has obtained, a judge orders her to undergo a 10-day psychiatric evaluation. What is the most probable psychiatric diagnosis for this client? a) Delusional disorder — jealous type b) Schizophreniform disorder c) Induced psychotic disorder d) Delusional disorder — erotomanic type

Delusional disorder — erotomanic type

A couple is speaking with a nurse about their ambivalence about sending their adult son with schizophrenia to residential placement. They tell the nurse that neither keeping their son at home nor sending him to a facility is a satisfactory solution for them. What should the nurse keep in mind when planning to discuss this situation with the family? Select all that apply. a) Suggesting a psychiatric evaluation for the son b) Investigating all potential care options c) Implementing what's best for the couple d) Consulting the legal system for information e) Reviewing the client's treatment history

Investigating all potential care options • Reviewing the client's treatment history

A major role in crisis intervention is getting a client's family and friends involved in helping with the immediate crisis as soon as possible. The nurse should determine that the support persons are prepared to help when they verbalize what information? a) the coping strategies they are using b) emergency resources and when to use them c) long-term solutions they plan to tell the client to use d) the name and phone number of the client's health care provider (HCP)

emergency resources and when to use them

The nurse correctly judges that the danger of a suicide attempt is greatest with which client behavior? a) increase in energy level b) at the point of deepest despair c) resumption of former lifestyle d) willingness to visit with an estranged brother

increase in energy level

When coping becomes dysfunctional enough to require the client to be admitted to the hospital, the nurse expects that the client would be exhibiting what behaviors? a) tension reduction activities and then problem solving b) anger management strategies with no problem solving c) objective and rational problem solving d) minimal functioning with new problems developing

minimal functioning with new problems developing

Which nursing intervention is the highest priority when a client is placed in restraints? a) monitoring the client every 15 minutes b) assisting with nutrition and elimination c) performing range-of-motion exercise for each limb, one at a time d) changing the client's position every 2 hours

monitoring the client every 15 minutes

An elderly client who has been diagnosed with delusional disorder for many years is exhibiting early symptoms of dementia. His daughter lives with him to help him manage daily activities, and he attends a day care program for seniors during the week while she works. A nurse at the day care center hears him say, "If my neighbor puts up a fence, I will blow him away with my shotgun. He has never respected my property line, and I have had it!" Which action should the nurse take? a) Observe the client more closely, but do not report his threat since he will likely not be able to follow through with it because of his dementia. b) Report the comment to the neighbor, the intended victim, but refrain from telling the daughter since she will just worry about actions of her father she cannot control. c) Report the comment to the neighbor, the daughter, and the police since there is the potential for a criminal act. d) Report the comment to the client's daughter so she can observe him more closely, but refrain from telling the neighbor due to privacy regulations.

Report the comment to the neighbor, the daughter, and the police since there is the potential for a criminal act.

An elderly client was prescribed lorazepam 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. Which finding would the nurse suspect as the cause of the mother's behavior, and what action would she suggest? a) The client is experiencing a medication interaction and should go to the emergency department. b) The client is experiencing a paradoxical reaction to the lorazepam and should stop the new medication immediately. c) The client is experiencing mania and may need a sleeping pill. d) The client is overcome by grief and probably needs an antidepressant.

The client is experiencing a paradoxical reaction to the lorazepam and should stop the new medication immediately.

The nurse manager on a psychiatric unit is reviewing the outcomes of staff participation in an aggression management program. What indicator would the nurse used to evaluate the effectiveness of such a program? a) a reduction in the number of complainsts by clients' relatives b) a reduction in the total number of restraint procedures c) fewer client injuries during restraint procedures d) fewer staff injuries during restraint procedures

a reduction in the total number of restraint procedures

When a client expresses feelings of unworthiness, the nurse should respond by saying: a) "It would be best to try to forget the idea that you are unworthy." b) "Your family loves you even if you feel unworthy." c) "As you begin to feel better, your feelings of unworthiness will begin to disappear." d) "Your feelings of being unworthy are just your imagination."

"As you begin to feel better, your feelings of unworthiness will begin to disappear."

A nurse has been working with a battered woman who is being discharged and returning home with her husband. The nurse says, "All this work with her has been useless. She is just going back to him as usual." Which statement by a nursing colleague would be most helpful to this nurse? a) "These women almost never leave for good because of their emotional and financial dependency." b) "Her reasons for staying are complex. She can leave only when she is ready and can be safe." c) "I know it is frustrating to work with clients who do not follow our advice." d) "You did your best. You will see her again and have another chance."

"Her reasons for staying are complex. She can leave only when she is ready and can be safe."

In the process of dealing with the intense feelings about being raped, victims commonly verbalize that they were afraid they would be killed during the rape and wish that they had been. The nurse should decide that further counseling is needed if the client makes which statement? a) "I wish they gave the death penalty to all rapists and other sexual predators." b) "Suicide would be an easy escape from all this pain, but I could not do it to myself." c) "I get so angry at times that I have to have a couple of drinks before I sleep." d) "I did not fight him, but I guess I did the right thing because I am alive."

"I get so angry at times that I have to have a couple of drinks before I sleep."

Which statement indicates to the nurse that the client is progressing toward recovery from a somatoform disorder? a) "My stomach pain will go away once I get properly diagnosed." b) "I understand my pain will feel worse when I am worried about my divorce." c) "I need to find a health care provider who understands what my pain is like." d) "My headache feels better when I time my medication dose."

"I understand my pain will feel worse when I am worried about my divorce."

Which statement indicates to the nurse that the client is progressing toward recovery from a somatoform disorder? a) "I need to find a health care provider who understands what my pain is like." b) "My stomach pain will go away once I get properly diagnosed." c) "I understand my pain will feel worse when I am worried about my divorce." d) "My headache feels better when I time my medication dose."

"I understand my pain will feel worse when I am worried about my divorce."

Which statement is the best wording of a no-harm, no-suicide contract? a) "I will not kill myself until after talking to my healthcare provider." b) "I will not think about killing myself." c) "I will not kill myself unless my wife dies." d) "I will not accidentally or purposely kill myself during the next 24 hours."

"I will not accidentally or purposely kill myself during the next 24 hours."

The client exhibits a flat affect, psychomotor retardation, and depressed mood. The nurse attempts to engage the client in an interaction but the client does not respond to the nurse. Which response by the nurse is most appropriate? a) "I will get you something to read." b) "I will find someone else for you to talk with." c) "I will come back a little bit later to talk." d) "I will sit here with you for 15 minutes."

"I will sit here with you for 15 minutes."

A client is admitted to the hospital because of threatening, aggressive behavior toward his family. In the first group meeting after the client is admitted, another client sits near the nurse and says loudly, "I'm sitting here because I'm afraid of Ted. He's so big, and I heard him talk about hitting people." The nurse should say to the client: a) "Everyone is here for different problems. You know you don't have to worry." b) "It's frightening to have new people on the unit. We're here to talk about things like being afraid." c) "You don't know Ted yet. Once you get to know him, I'm sure you won't be afraid." d) "Ted is new to the group. Let's go around and introduce ourselves to him."

"It's frightening to have new people on the unit. We're here to talk about things like being afraid."

Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which conditions? a) Increased appetite, slowing of sensorium, and arrhythmias b) Hypotension, weight gain, and listlessness c) Tachycardia, weight loss, and mood swings d) Hyperpyrexia, slow pulse, and weight gain

Tachycardia, weight loss, and mood swings

A woman who was raped in her home was brought to the emergency department by her husband. After being interviewed by the police, the husband talks to the nurse. "I do not know why she did not keep the doors locked like I told her. I cannot believe she has had sex with another man now." The nurse should respond by saying: a) "Your wife needs your support right now, not your criticism." b) "Maybe the doors were locked, but the man broke in anyway." c) "Let us talk about how you feel. Maybe it would help to talk to other men who have been through this." d) "It was not consensual sex. Let us see if your wife was physically injured."

"Let us talk about how you feel. Maybe it would help to talk to other men who have been through this."

An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help? a) "Get the hydraulic lift; the client is still groggy." b) "Obtain the sliding board or two other people to assist us." c) "Place the client on his side; then use a drawsheet to bring him to the bed." d) "Place the client in a semi-Fowler's position. Doing so will make the move easier."

"Obtain the sliding board or two other people to assist us."

A client with severe and persistent depression can't decide if he'll undergo electroconvulsive therapy (ECT). His family asks a nurse to convince him that this treatment modality would be beneficial. In educating the family about the client's situation, what statement about client rights should the nurse make? a) "The client, treatment team, and family must meet to discuss this treatment option." b) "You must have the client sign a statement that he understands the treatment benefits but still declines the treatment." c) "You must make the client aware of the moral aspects of refusing treatment." d) "In a situation like this, the family should obtain legal counsel for the client."

"The client, treatment team, and family must meet to discuss this treatment option."

client with severe and persistent depression can't decide if he'll undergo electroconvulsive therapy (ECT). His family asks a nurse to convince him that this treatment modality would be beneficial. In educating the family about the client's situation, what statement about client rights should the nurse make? a) "You must make the client aware of the moral aspects of refusing treatment." b) "In a situation like this, the family should obtain legal counsel for the client." c) "The client, treatment team, and family must meet to discuss this treatment option." d) "You must have the client sign a statement that he understands the treatment benefits but still declines the treatment."

"The client, treatment team, and family must meet to discuss this treatment option."

A 35-year-old man was experiencing martial discord with his wife of 4 years. When his wife walked out, he became angry, throwing things and breaking dishes. A friend talked him into seeking help at the local mental health center. Which question should the nurse ask initially to begin to assess this man's immediate problem? a) "What led you to come in for help today?" b) "In hindsight, how might you have managed this situation differently?" c) "What did you do to cause your wife to leave?" d) "Do you feel in control of yourself at this time?"

"What led you to come in for help today?"

A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate, the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required? a) "I can still eat my favorite salty foods." b) "When my moods fluctuate, I'll increase my dose of lithium." c) "A good blood level of the drug means the drug concentration has stabilized." d) "Eating too much watermelon will affect my lithium level."

"When my moods fluctuate, I'll increase my dose of lithium."

The client, who is dying from acquired immunodeficiency syndrome (AIDS), is admitted to the inpatient psychiatric unit because he attempted suicide. His close friend recently died from AIDS. The client states to the nurse, "What is the use of living? My time is running out." What is the nurse's best response? a) "Life is precious and worth living." b) "Do not give up. There could be a cure for AIDS tomorrow." c) "Let us talk about making some good use of that time." d) "You are in a lot of pain. What are you feeling?"

"You are in a lot of pain. What are you feeling?"

The decision is made to involuntarily admit a client to a psychiatric hospital on an emergency detention. The nurse explains the involuntary hospitalization process to the client. Which of the following statements made by the nurse would not be accurate about the involuntary admission process? a) "You cannot have any visitors while you're here involuntarily." b) "You're in the hospital because the psychiatrist who saw you earlier thinks that you are unable to care for yourself right now." c) "You're free to talk to a lawyer if you'd like to do so." d) "You cannot leave the hospital until the primary health care provider thinks you can take care of yourself."

"You cannot have any visitors while you're here involuntarily."

A client states the following to the nurse: "I am a failure, and I wish I had died." Which of the following statements by the nurse demonstrates a therapeutic response? a) "You feel like a failure; would you like to talk more about the way you feel?" b) "You are depressed right now, so feeling like a failure is a normal manifestation." c) "I am glad to hear you speak about your feelings and I am glad you did not die." d) "I think you have had many successes in your life and you should focus on them."

"You feel like a failure; would you like to talk more about the way you feel?"

A nurse is working in the emergency room when a police officer walks in with a rape victim to be examined. If the nursing goal is to reduce client anxiety, which interventions would be appropriate? Select all that apply. a) Allow a third party to be present if the client requests it. b) Touch the client early on demonstrating the nurse is supportive. c) Assure the client of safety in the examination room. d) Admit the client to the treatment area right away. e) Ask factual questions to determine the type of assault. f) Encourage the client to undergo an examination immediately in order to get it behind her.

Admit the client to the treatment area right away. • Assure the client of safety in the examination room. • Allow a third party to be present if the client requests it. • Ask factual questions to determine the type of assault.

An experienced nurse is precepting a new nurse in a psychiatric emergency room and is discussing criteria for involuntary commitment. Which client would signal to the experienced nurse that the new nurse understands the criteria? a) A client with schizophrenia who can manage activities of daily living but has grandiose delusions b) A woman with depression who says she is tired of living and does not have a suicidal plan c) A man who threatens to kill his wife of 38 years d) The parent who leaves her minor children unattended and stays out all night snorting cocaine

A man who threatens to kill his wife of 38 years

Which reaction to learning about a diagnosis of being HIV positive would put the client at the greatest need of intervention by the nurse? a) A person who says, "I have found a solution for this mess." b) A person who is angry, hostile, and alienated from their family. c) A person who is obsessed with cleanliness and showers many times a day. d) A person who is unable to make decisions and is helpless and tearful.

A person who says, "I have found a solution for this mess."

Which principle of the psychoanalytic model is particularly useful to psychiatric nurses? a) Behavior that is reinforced will be perpetuated. b) All behavior has meaning. c) The first 6 years of a person's life determine personality. d) Behavioral deviations result from an incongruence between verbal and nonverbal communication.

All behavior has meaning.

The nurse meets with a client in the outpatient clinic who is suicidal and refuses to sign a "no suicide" contract. What should the nurse do next? a) Arrange for immediate hospitalization on a locked unit. b) Arrange for admission to a subacute unit for 2 weeks. c) Arrange for the client to be sent back to the group home. d) Refer the client to a partial program until the client is no longer suicidal.

Arrange for immediate hospitalization on a locked unit.

A client scans the adult inpatient unit on arrival at the hospital. The client is neatly dressed and clutches a leather briefcase. The client refuses to let the nurse touch the briefcase to check it for valuables or contraband. Which action by the nurse would be best? a) Ask the client to open the briefcase and describe its contents. b) Inspect the briefcase when the client is temporarily out of the room. c) Tell the client that he must follow hospital policy if he wishes to stay. d) Obtain help to take the briefcase away from the client.

Ask the client to open the briefcase and describe its contents.

During a unit meeting attended by clients and staff, several clients are criticizing their primary nurses. These clients have also been intimidating two other clients who have recently been admitted to the unit, and now the new clients have stopped sharing their opinions during the meeting. What is the first action for the nurse to take? a) Ask the clients criticizing their nurses to suggest some possible solutions for the practices they are criticizing. b) Help the new clients express the reasons they have stopped sharing their ideas. c) Give the clients who are publicly criticizing the nurses a verbal warning that this behavior is not acceptable. d) Use the next unit meeting to discuss respect and the importance of collaboration with the treatment team.

Ask the clients criticizing their nurses to suggest some possible solutions for the practices they are criticizing.

While listening to a taped-report at shift change, one of the other team members remarks that "My mother lives near this client, and his yard is always full of junk." What should the nurse assigned to provide care to this client do in this situation? a) Ignore the comment. b) Ask the team member what the purpose was in sharing the information. c) Ask the team member to be quiet. d) Include the information in report for the next shift.

Ask the team member what the purpose was in sharing the information.

A nurse working at an outpatient mental health center primarily with chronically mentally ill clients receives a telephone call from the mother of a client who lives at home. The mother reports that the client has not been taking her medication and now is refusing to go to the work center where she has worked for the past year. What should the nurse do first? a) Make an appointment for the client to see the health care provider (HCP). b) Ask to speak to the client directly on the phone. c) Call the director of the work center for information about the client. d) Reserve an inpatient bed in preparation for the client's admission.

Ask to speak to the client directly on the phone.

A client is to be discharged from an alcohol rehabilitation program. What should the nurse emphasize in the discharge plan as a priority? a) follow-up care b) supportive friends c) a list of goals d) returning to work

follow-up care

A client in an acute care mental health program refuses his morning dose of an oral antipsychotic medication and believes he's being poisoned. The nurse should respond by taking which action? a) Consulting with the physician about a care plan. b) Omitting the dose and trying again the next day c) Administering the medication by injection d) Crushing the medication and putting it in his food

Consulting with the physician about a care plan.

A 5-year-old child exhibits signs of extreme restlessness, short attention span, and impulsiveness. Which intervention by the nurse would be therapeutic for this child? a) Limit the child's opportunities to verbalize anger and frustration. b) Restrict the child's participation in physical activities. c) Define behaviors that are acceptable and behaviors that are not permitted. d) Increase the child's sensory stimulation.

Define behaviors that are acceptable and behaviors that are not permitted.

A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse responds, "You may want to talk about your employment situation in group today." The nurse is using which therapeutic technique? a) Exploring b) Making observations c) Restating d) Focusing

Focusing

A physician has ordered a new antipsychotic medication for a client with schizophrenia whose previous medication no longer provides the expected symptom relief. When the client tells the nurse that he cannot afford the additional cost of this new medication, what is the first action the nurse should take to help the client advocate for his needs? a) Talk with the client and the physician about whether this particular drug is necessary. b) Help the client explore other financial options for obtaining medication reimbursement with a social worker. c) Teach the client to accept the fact that he cannot get full reimbursement for the cost of the medication. d) Suggest that the client contact a legal representative about the situation.

Help the client explore other financial options for obtaining medication reimbursement with a social worker.

Which finding indicates that a client who has been raped will have future adjustment problems and need additional counseling? a) Her parents show shame and suspicion about her part in the rape. b) She seeks support from formerly ignored relatives and friends. c) She becomes upset when talking about the rape to anyone. d) Her life becomes focused on helping other rape victims like herself.

Her parents show shame and suspicion about her part in the rape.

At 1000 hours, a client with a diagnosis of pain disorder demands that the nurse call the health care provider (HCP) for more pain medication because she is still in pain after the 0900 analgesic. What should the nurse do next? a) Suggest the client lie down while she is waiting for her next dose. b) Call the HCP as the client requests. c) Inform the client that the nurse cannot give her additional medication at this time. d) Tell the client that the HCP will be in later to talk to her about it.

Inform the client that the nurse cannot give her additional medication at this time.

A nurse is explaining medication benefits and adverse effects to a client with a history of psychosis. The client's brother tells the nurse that she's wasting her time explaining things to the client. What information about informed consent should the nurse use to respond to the brother's negative statement? a) Informed consent doesn't apply to clients who experience psychosis. b) A third party must be present when a nurse informs clients about treatment options. c) The nurse may assume that the client understands at least some of the information. d) Informed consent is an important part of effective client care that helps accomplish treatment goals.

Informed consent is an important part of effective client care that helps accomplish treatment goals.

A client who has experienced the loss of her husband through divorce, the loss of her job and apartment, and the development of drug dependency is suffering situational low self-esteem. Which outcome is most appropriate initially? a) The client will identify two positive qualities. b) The client will discuss her feelings related to her losses. c) The client will prioritize problems. d) The client will explore her strengths.

The client will discuss her feelings related to her losses.

A 19-year-old male with cystic fibrosis (CF) is hospitalized for a serious lung infection and is in need of a lung transplant. However, he has a rare blood type that complicates the process of obtaining a donor organ. He has also been diagnosed with bipolar disorder and treated successfully since mid-adolescence with medication and therapy. The client requests to see a chaplain to help him make plans for a funeral and donation of his body to science after death. How should the nurse interpret the client's request? a) It is a signal of the client's growing awareness that he is likely to have a shortened lifespan and should be supported by unit staff. b) It is a signal of an exacerbation of the client's CF and warrants further assessment by his lung specialist. c) It is a signal of the depressive side of his bipolar disorder, and he should be checked for suicidal thoughts/plans. d) It is a signal of delirium as a result of the many medications the client is taking and requires further assessment by the pharmacist or health care provider (HCP).

It is a signal of the client's growing awareness that he is likely to have a shortened lifespan and should be supported by unit staff.

A client in group therapy is restless. His face is flushed and he makes sarcastic remarks to group members. The nurse responds by saying, "You look angry." The nurse is using which technique? a) A broad, opening statement b) Reassurance c) Clarifying d) Making observations

Making observations

A client who has experienced the loss of her husband through divorce, the loss of her job and apartment, and the development of drug dependency is suffering situational low self-esteem. Which outcome is most appropriate initially? a) The client will prioritize problems. b) The client will identify two positive qualities. c) The client will discuss her feelings related to her losses. d) The client will explore her strengths.

The client will discuss her feelings related to her losses.

A client doesn't make eye contact with the nurse during an interview. The nurse suspects that the client's behavior has a cultural basis. What should the nurse do first? a) Ask staff members of a similar culture about the client's behavior. b) Read several articles about the client's culture. c) Observe how the client and the client's family and friends interact with one another and with other staff members. d) Accept the client's behavior because it's probably culturally-based.

Observe how the client and the client's family and friends interact with one another and with other staff members.

A client is irritable and hostile. He becomes agitated and verbally lashes out when his personal needs are not immediately met by the staff. When the client's request for a pass is refused by the healthcare provider, he utters a stream of profanities. Which statement best describes the client's behavior? a) The client's anger is a reliable sign of serious pathology. b) The client's anger is not intended personally. c) The client's anger is a sign that his condition is improving. d) The client's anger is an intended attack on the healthcare provider's skills.

The client's anger is not intended personally.

The widow of a client who successfully completed suicide tearfully says, "I feel guilty because I am so angry at him for killing himself. It must have been what he wanted." After assisting the widow with dealing with her feelings, which intervention is most helpful? a) Refer her to a group for survivors of suicide. b) Suggest she receive individual therapy by the nurse. c) Provide her with the local suicide hotline number. d) Encourage her to receive counseling from a chaplain.

Refer her to a group for survivors of suicide.

A client walks into the clinic and tells the nurse she wants to die because her boyfriend broke up with her. The client states, "I will show him. He will be sorry." The nurse notes which underlying theme and method to deal with the client? a) Retaliation—ask client about her specific plans to harm herself and/or her boyfriend. b) Sadness—ask client to reveal how long she has felt this way. c) Escape—ask client to indicate what she wants to escape. d) Loneliness—ask client to state who she believes to be her friends.

Retaliation—ask client about her specific plans to harm herself and/or her boyfriend.

The nurse is admitting a client with Borderline Personality Disorder. When planning care for this client, the nurse should give priority to which item? a) Empathy b) Manipulation c) Splitting d) Safety

Safety

A client who is neatly dressed and clutching a leather briefcase tightly in his arms scans the adult inpatient unit on his arrival at the hospital and backs away from the window. The client requests that the nurse move away from the window. The nurse recognizes that doing as the client requested is contraindicated for which reason? a) The action will make the client feel that the nurse is humoring him. b) The client will then think that he will have his way when he wishes. c) The action indicates nonverbal agreement with the client's false ideas. d) The nurse will be demonstrating a lack of composure over the situation.

The action indicates nonverbal agreement with the client's false ideas.

A client is admitted to an inpatient psychiatric unit. After the assessment and admission procedures have been completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in the corner of the dayroom." What is the rationale for communicating these planned nursing interventions? a) To provide a structured environment for the client b) To provide time for completing nursing responsibilities c) To instill hope in the client d) To attempt to establish a trusting relationship

To attempt to establish a trusting relationship

Emergency restraints or seclusion may be implemented without a physician's order under which condition? a) Never b) When a licensed practitioner will do a face-to-face assessment within 1 hour c) When a child is acting out d) If a voluntary client wants to leave against medical advice

When a licensed practitioner will do a face-to-face assessment within 1 hour

When preparing to use seclusion as an alternative to restraint for a client who has not yet lost control, the nurse expects to use a room with limited furniture and no access to dangerous articles. What should the nurse also consider as critical for the safety of the client? a) a staff member to stay in the room with the client b) a prescription for the seclusion before it is initiated c) a security window in the door or a room camera d) lights that can be dimmed from outside the room

a security window in the door or a room camera

A client on haloperidol has stiff muscles, restlessness, and internal jumpiness. The client has all of the following medications prescribed as needed. Which one would be most appropriate for the nurse to administer to decrease the client's symptoms? a) benztropine b) lorazepam c) olanzapine d) trazodone

benztropine

What is a crucial goal of therapeutic communication when helping the client deal with personal issues and painful feelings? a) communicating empathy through gentle touch b) guaranteeing total confidentiality and anonymity for the client c) conveying client respect and acceptance even if not all of the client's behaviors are tolerated d) mutual sharing of information, spontaneity, emotions, and intimacy

conveying client respect and acceptance even if not all of the client's behaviors are tolerated

The health care provider (HCP) refers a client diagnosed with somatization disorder to the outpatient clinic because of problems with nausea. The client's past symptoms involved back pain, chest pain, and problems with urination. The client tells the nurse that the nausea began when his wife asked him for a divorce. Which intervention is most appropriate? a) informing the client about a different medication for his nausea b) allowing the client to talk about the HCPs he has seen and the medications he has taken c) asking the client to describe his problem with nausea d) directing the client to describe his feelings about his impending divorce

directing the client to describe his feelings about his impending divorce

A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to: a) place the client in full leather restraints. b) establish a rapport to foster trust. c) ensure safety by initiating suicide precautions. d) try to communicate with the client in writing.

ensure safety by initiating suicide precautions.

A nurse is using drawing, puppetry, and other forms of play therapy while treating a terminally ill, school-age child. The purpose of these techniques is to help the child: a) have a good time while he's in the hospital. b) accept responsibility for his situation. c) express feelings that he can't articulate. d) internalize his feelings about death and dying.

express feelings that he can't articulate

A nurse is using drawing, puppetry, and other forms of play therapy while treating a terminally ill, school-age child. The purpose of these techniques is to help the child: a) accept responsibility for his situation. b) have a good time while he's in the hospital. c) internalize his feelings about death and dying. d) express feelings that he can't articulate.

express feelings that he can't articulate.

The nurse manager of a psychiatric unit notices that one of the nurses commonly avoids a 75-year-old client's company. Which factor should the nurse manager identify as being the most likely cause of this nurse's discomfort with older clients? a) fears and conflicts about aging b) dislike of physical contact with older people c) recent experiences with her mother's elderly friends d) a desire to be surrounded by beauty and youth

fears and conflicts about aging

A client changes topics quickly while relating past psychiatric history. This client's pattern of thinking is called: a) flight of ideas. b) tangential thinking. c) looseness of association. d) circumstantial thinking.

flight of ideas.

The client approaches various staff with numerous requests and needs to the point of disrupting the staff's work with other clients. The nurse meets with the staff to decide on a consistent, therapeutic approach for this client. Which approach will be most effective? a) having the client discuss needs with the staff person assigned b) telling the client to stay in his room until staff approach him c) limiting the client to the dayroom and dining area d) giving the client a list of permissible requests

having the client discuss needs with the staff person assigned

A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. When assessing the client on admission, the nurse should first ask the client: a) how he sleeps at night. b) if he is thinking about hurting himself. c) how he feels about himself. d) about recent stresses.

if he is thinking about hurting himself.

The nurse correctly judges that the danger of a suicide attempt is greatest with which client behavior? a) at the point of deepest despair b) willingness to visit with an estranged brother c) increase in energy level d) resumption of former lifestyle

increase in energy level

A mute client begins to express herself verbally on occasion. Which nursing action should be credited with helping a mute client express herself verbally? a) making open-ended statements followed with silence b) using hand signals to entice the client to communicate c) expressing perceptions about what the client is experiencing d) asking direct questions that draw the client out

making open-ended statements followed with silence

A client with schizophrenia started risperidone 2 weeks ago. Today, he tells the nurse he feels like he has the flu. The nurse's assessment reveals the following: temperature 104.4° F (40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute. The nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing: a) neuroleptic malignant syndrome. b) septicemia. c) the flu. d) malignant hyperthermia.

neuroleptic malignant syndrome.

The charge nurse in an acute care setting assigns a client who is on one-on-one suicide precautions to a psychiatric aide. This assignment is considered: a) poor nursing practice because a registered nurse should work with this client. b) an illegal delegation. c) outside the responsibility of an aide. d) reasonable nursing practice because one-on-one requires the total attention of a staff member.

reasonable nursing practice because one-on-one requires the total attention of a staff member.

The nurse who uses self-disclosure should: a) have the client explain his perception of what the nurse has revealed. b) refocus on the client's experience as quickly as possible. c) allow the client to ask questions about her own experience. d) discuss her experience in detail.

refocus on the client's experience as quickly as possible.

A client refuses his evening dose of haloperidol and then becomes extremely agitated in the day room while other clients are watching television. He begins cursing and throwing furniture. The nurse's first action is to: a) place the client in full leather restraints. b) check the client's medical record for an order for an as-needed dose of medication for agitation. c) remove all other clients from the day room. d) call the physician and report the behavior.

remove all other clients from the day room.

A client has been involuntarily committed to a hospital because he has been assessed as being dangerous to self or others. The client has lost which right? a) the right to leave the hospital against medical advice b) the right to refuse medications and treatments c) the right to send and receive uncensored mail d) freedom from seclusion and restraints

the right to leave the hospital against medical advice

A client with bipolar disorder is taking lithium carbonate 300 mg t.i.d. His lithium level is 2.7 mEq/L. In assessing the client at his clinic visit, the nurse finds no evidence of lithium toxicity. The first assessment question the nurse should ask before ordering another blood test is: a) whether the client is experiencing depression and having suicidal ideation. b) when the client took his last dose of lithium. c) whether the client understands why he's taking this medication. d) whether the client is embarrassed or afraid to report medication problems.

when the client took his last dose of lithium.