Menatal Health/BH Hesi V2

a woman arrives in the emergency center and tells the nurse she thinks she has been raped.. the client is sobbing and expresses disbelief that a rape could happen bc the man is her best friend.. after acknowledging the clients fear and anxiety, how should the nurse respond A. I would be very upset and mad if my best friend did that to meB. You must feel betrayed, but maybe you might have led him onC. Rape is not limited to strangers and frequently occurs by someone who is known to the victimD. This does not sound like rape. Did you change your mind about having sex after the fact?

"rape is not limited to strangers and frequently occurs by someone who is known to the victim": a victim of date rape or acquaintance rape is less prone to recognize what is happening bc the incident usually involves persons who know each other and the dynamics are different than rape by a stranger.. this response provides confrontation for the clients denial bc the victim frequently knows and trusts the perpetrator

a male client is brought to the emergency department by a police officer, who reports the client was disturbing the peace by running naked in the street, striking out at others, and smashing care windows.. which behaviors should the client demonstrate to determine if he should be evaluated for involuntary commitment A. Threats to kill his friend.B. Disruptive behaviors in a community setting.C. Hears voices telling him to kill himself.D. Reports he has not needed a bath in 4 months.E. Created extensive private property damage.F. Says he has not eaten in 3 days.

- threats to kill his friend - hears voices telling him to kill himself - reports he has not needed a bath in 4 months - says he has not eaten in 3 days most states provide for emergency involuntary hospitalization or civil commitment for a specified period to prevent dangerous behavior that is likely to cause harm to self or others.. police officers and HCPs may be designated by statute to authorize the detention of persons who are a danger to themselves or others who are unable to provide for their own basic needs due to mental illness

a client, who is on a 30 day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center.. when he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. What responses are appropriate for the nurse to use? (select all that apply) A. Call a staff member to escort the client to his roomB. Ask the client to talk about what is causing him to upsetC. Ignore the client inappropriate behavior D. Remind the client of the unit rulesE. Tell the client to talk to his healthcare provider about his privileges

Ask the client to talk about what is causing him to be upset Remind the client of the unit rules

the nurse is leading a "current evens group" with chronic psychiatric clients.. one group member states "Clara Barton was my nurse during my last hospitalization.. she was a very mean nurse and wasn't nice to me".. which response is best for the nurse to make - Clara Barton was not your nurse. - What did she do to you that was so mean? - I didn't know that Clara Barton was a nurse. - Clara Barton started the American Red Cross.

Clara Barton started the American red cross: this response presents the reality of the situation in relation to American culture.. the fact that Clara Barton was a nurse during the American civil war should be addressed on an individual basis.. since this is group therapy, the nurse would be illustrating the concept of universality

a client is admitted with a diagnosis of depression.. the nurse knows that which characteristic is most indicative of depression A. Grandiose ideation B. Self-destructive thoughts.C. Suspiciousness of othersD. A negative view of self and the future

a negative view of self and the future: negative self image and feelings of hopelessness about the future are specific indicators for depression

a female client with OCD is describing her obsessions and compulsions and asks the nurse why these make her feel safer.. what information should the nurse include in this clients teaching plan - Compulsions relieve anxiety. - Anxiety is the key reason for OCD. - Obsessions cause compulsions. - Obsessive thoughts are linked to levels of neurochemicals. - Antidepressant medications increase serotonin levels.

- compulsions relieve anxiety - anxiety is the key reason for OCD - obsessive thoughts are linked to levels of neurochemicals - antidepressant meds increase serotonin levels to promote client understanding and compliance, the teaching plan should include explanations about the origin and treatment options of OCD symptomology.. compulsions are behaviors that help relieve anxiety, which is a vague feeling related to unknown fears, that motivate behavior to help the client cope and feel secure.. all obsessions do not result in compulsive behavior.. OCD is supported by the neurophysiology theory, which attributes a diminished level of neurochemicals, particularly serotonin, and responds to SSRIs

which client should the nurse identify as the highest risk for the onset of stress related problems A. A man whose new business is growing slowly, who plans to adopt a child with his wife, and says, I think I'm in control of my destiny. B. A woman who is graduating from college, getting married in one month, and states, I'm anticipating the changes these events will make in my life. C. A client who is passed over for promotion, quits a job to start a new business, and states, This is just one of a series of challenges I've faced in my life. D. A person whose father died three months ago, who is losing a job due to company downsizing, and states, Living with loss and the threat of loss makes me feel helpless.

a person whose father died three months ago, who is losing a job due to company downsizing, and states, living with loss and the threat of loss makes me feel helpless: a client who is dealing with two stressful life events and expresses a cognitive appraisal of loss and helplessness is at the highest risk for a stress related health problem

an anxious client expressing a fear of people and open places is admitted to the psychiatric unit.. what is the most effective way for the nurse to assist this client A. Plan an outing within the first week of admission.B. Distract her whenever she expresses her discomfort about being with others.C. Confront her fear and discuss the possible causes of these fears.D. Accompany her outside for an increasing amount of time each day.

accompany her outside for an increasing amount of time each day: the process of gradual desensitization by controlled exposure to the situation which is feared is the treatment of choice in phobic reactions

an adolescent who attempted suicide with drug OD arrives in the ED with an empty 30 tab bottle of acetaminophen.. which action should the nurse implement

adminster acetylcysteine (Mucomyst): tylenol OD is treated with immediate administration of Mucomyst to prevent hepatic insult

a 45 year old female client is admitted to the psychiatric unit for evaluation.. her husband states that she has been reluctant to leave home for the last six months.. the client has not gone to work for a month and has been terminated from her job.. she has not left the house since that time.. this client is displaying symptoms of what condition A. Claustrophobia B. AcrophobiaC. AgoraphobiaD. Post-traumatic stress disorder

agoraphobia: agoraphobia is the fear of crowds or being in an open place.. remember a phobia is an unrealistic fear which is associated with severe anxiety

over a period of several weeks, one male participant of a socialization group at a community day care center for the elderly monopolizes most of the groups time and interrupts others when they are talking.. what is the best action for the nurse to take in this situation A. Talk to the client outside the group about his behavior during group meetings.B. Remind the client to allow others in the group a chance to talkC. Allow the group to handle the problem D. Ask the client to join another group

allow the group to handle the problem: after several weeks, the group is in the working phase and the group members should be allowed to determine the direction of the group.. the nurse should ignore the clients comments and allow the group to handle the situation.. a good leader should not have separate meetings with group members.. remember, identify what phase the group is in-- initial, working, or termination-- this will help determine communication style

within several days of hospitalization, a client is repeatedly washing the top of the same table.. which intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior A. Administer a prescribed PRN antianxiety medication. B. Assist the client to identify stimuli that precipitates the ritualistic activity.C. Allow time for the ritualistic behavior, then redirect the client to other activities.D. Teach the client relaxation and thought stopping techniques.

allow time for the ritualistic behavior, then redirect the client to other activities: initially, the nurse should allow time for the ritual to prevent anxiety

a 65 year old female client complains to the nurse that recently she has been hearing voices.. what question should the nurse ask this client first - Do you have problems with hallucinations? - Are you ever alone when you hear the voices? - Has anyone in your family had hearing problems? - Do you see things that others cannot see?

are you ever alone when you hear the voices: determining if the client is alone when she hears voices will assist in differentiating between hallucinations and hearing loss.. this is especially important in the aging population

a young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him.. what intervention should the nurse include in this clients plan of care A. Remind the client that his suspicions are not true. B. Ask one nurse to spend time with the client daily.C. Encourage the client to participate in the group activities.D. Assign the client a room closest to the activity room.

ask one nurse to spend time with the client daily: a client with paranoid schizophrenia has difficulty with trust and developing a trusting relationship with one nurse is likely to be therapeutic for this client

a client with a history of alcoholism with a compound fracture of the femur after falling down the previous night.. what additional assessment should be the priority focus for the nurse A. Collect a specimen for a blood alcohol level (BAL).B. Do nothing because the time for BAL determination is passed.C. Review the results of a Breathalyzer obtained in the emergency department upon admission.D. Ask the client about the quantity, frequency, and time the last alcohol drink was ingested.

ask the client about the quantity, frequency, and time the last alcohol drink was ingested: the priority assessment is to determine the clients risk for alcohol withdrawal, which can appear within 48 hours since ingestion of the last alcoholic drink, so this is the priority

the nurse is planning care for a 32 year old male client diagnosed with HIV infection who has a history of chronic depression.. recently, the clients viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen.. what should the nurse do first while taking the clients history upon admission to the hospital A. Determine if the client attends a support group weekly.B. Hold all antidepressant medications until further notice.C. Ask the client if he takes St. John's Wort routinely.D. Have the client describe any recent changes in mood.

ask the client if he takes St. Johns Wort routinely: St. Johns Wort, an herbal preparation, is an alternative (nonconventional) therapy for depression, but it may adversely interact with medications used to treat HIV infection.. the nurses top priority upon admission is to determine if the client has been taking this herb concurrently with HIV antiviral drugs, which may explain the rise in the viral load

a client who has a miscarriage at 10 weeks gestation tells the nurse that she already purchased some baby things and picked out a name.. after the surgical dilation and curettage, the client wants to go home as soon as possible.. based on the clients statements, which action should the nurse implement

ask the client what name she had picked out for the infant: the clients cues about her preparation for the baby indicate her need to express her feelings of loss, so encouraging further discussion about the infants name provides an opportunity to offer support

a client is told that her infant will be stillborn.. what is the most important action for the nurse to implement after the birth A.Ask the family if they would like to see and hold the infant after birth. B.Inquire if the parents want a picture taken after the infant is born.C.Discuss with the parents which funeral home should be notified.D.Find out if the client has a special outfit for the infant after the birth.

ask the family if they would like to see and hold the infant after birth: interventions and support from the nursing staff during a prenatal loss are extremely important in the grief process and healing of the parents.. research had shown it is most helpful for a mother and father to see and hold their deceased infant after delivery, so the parents should be given the opportunity initially after birth

a male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia.. during the admission procedure, the client looks up and states "no, its not my fault, you can't blame me, i didn't kill him, you did".. what action is best for the nurse to take - Reassure the client by telling him that his fear of the admission procedure is to be expected. - Tell the client that no one is accusing him of murder and remind him that the hospital is a safe place. - Assess the content of the hallucinations by asking the client what he is hearing. - Ignore the behavior and make no response at all to his delusional statements.

assess the content of the hallucinations by asking the client what he is hearing: further assessment is indicated.. the nurse should obtain information about what the client believes the voices are telling him--they may be telling him to kill the nurse!

the nurse is planning the care for a 32 year old male client with acute depression.. which nursing intervention best helps this client deal with his depression A. Ensure that the client's day is filled with group activitiesB. Assist the client in exploring feelings of shame, anger, and guiltC. Allow the client to initiate and determine activities of daily living. D. Encourage the client to explore the rationale for his depression

assist the client in exploring feelings of shame, anger, and guilt: depression is associated with feelings of shame, anger, and guilt.. exploring such feelings is an important nursing intervention for the depressed client

a client who is intoxicated is admitted for alcohol and multiple substance detoxification.. the nurse determines that the client is becoming increasingly anxious, agitated, and diaphoretic.. the client is also experiencing sensory perceptual disturbances and a clouded sensorium.. what is the priority nursing intervention for this client at this time A. Check on the client every 15 minutes.B. Begin one-on-one supervision immediately.C. Keep the room dimly lit and turn on the radio.D. Push fluids and provide calorie-rich nutritional supplements.

begin one on one supervision immediately: one on one supervision ensures the clients physical safety until the client is sedated adequately to reduce feelings of terror and tactile and visual hallucinations

the nurse is taking a history for a female client who is requesting a routine female exam.. which assessment finding requires follow up - Menstruation onset at age 9. - Contraceptive method includes condoms only. - Menstrual cycle occurs every 35 days. - "Black-out" after one drink last night on a date.

black out after one drink last night on a date: a "black out" typically occurs after ingestion of alcohol beverages that the client has no recall of the experiences or ones behaviors and is indicative of high blood alcohol levels, but the clients experience of a "black out" after one drink is suspicious of the client receiving a "date rape" drug and needs additional follow up

the community health nurse facilitates a substance abuse prevention group for a homeless population.. which statement demonstrates that a client has a realistic understanding of the recovery process

by learning what led to my latest relapse, i know what to do in the future: recovery is a lifelong process in which clients must constantly learn and apply new behaviors to replace ineffective ones.. every attempt toward recovery improves long term chances of success, so those who learn from their relapse demonstrate an understanding of the process

a client who abuses alcohol says to the nurse, i am glad i went in for treatment.. now my problems with alcohol are all behind me.. which response is best for the nurse to provide A. Yes, the treatment program you attended has an excellent success profile.B. Can you tell me more about what you mean when you say that your problems with alcohol are now behind you? C. You are likely to have a difficult time staying sober if you think that your problems with alcohol are behind you.D. Do you know what 'one day at a time' means for those who have problems with alcohol?

can you tell me more about what you mean when you say that your problems with alcohol are now behind you: those who attend alcohol treatment programs and AA never put drinking problems behind them and describe alcoholics as only one step away from a slip with maintaining sobriety.. the nurse should use reflection and encourage the client to further describe the feelings

at a support meeting of parents of a teenager with polysubstance dependency, a parent states "each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide".. the nurses response should be based on which information A. Addiction is a chronic, incurable disease.B. Tolerance to the effects of drugs causes feelings of depression.C. Feelings of depression frequently lead to drug abuse and addiction.D. Careful monitoring should be provided during withdrawal from the drugs.

careful monitoring should be provided during withdrawal from the drugs: the priority is to teach the parents that their son will need monitoring and support during withdrawal to ensure that he does not attempt suicide

the client with depression asks the nurse, "what are neurotransmitters? my doctor thinks my problem may lie with the neurotransmitters in my brain".. what information should the nurse use to support an explanation of neurotransmitters A. Chemical messengers that cause brain cells to turn on or off. B. Areas of the brain that are responsible for controlling emotions.C. Clumps of cells that alert the other brain cells to receive messages.D. Web-like structures that provide connections among parts of the brain.

chemical messengers that cause brain cells to turn on or off: neurotransmitters are chemicals manufactured in the brain that are responsible for exciting or inhibiting brain cells to produce an action

a client who is known to abuse drugs is admitted to the psychiatric unit.. which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms A. Perphenazine (Trilafon) B. Diphenhydramine (Benadryl)C. Chlordiazepoxide (Librium)D. Isocarboxazid (Marplan)

chlordiazepoxide (Librium): Librium, an anti anxiety drug, as well as other benzodiazepines, are used in titrated doses to reduce the severity of abrupt benzodiazepine withdrawal

a 52 year old male client in the ICU who has been oriented suddenly becomes disoriented and fearful.. assessment of VS and other physical parameters reveal no significant change and the nurse formulates the diagnosis "confusion related to ICU psychosis".. which intervention is best to implement A. Move all machines away from the client's immediate area. B. Attempt to allay the clients fears by explaining the etiology of his condition.C. Cluster care so that brief periods of rest can be scheduled during the day.D. Extend visitation times for family and friends

cluster care so that brief periods of rest can be scheduled during the day: the critical care environment confronts clients with an environment which provides stressors heightened by treatment modalities that may prove to be lifesaving.. these stressors can result in isolation and confusion.. the best intervention is to provide the client with rest periods

a client with substance abuse is admitted to the mental health unit.. which action should be implemented by the nurse, and not delegated to a UAP A. Provide menus for dietary selections.B. Clarify visiting hours and telephone usage.C. Collect a complete substance abuse history. D. Obtain vital signs and orient the client to the unit.

collect a complete substance abuse history: as part of a comprehensive assessment, the nurse should assess the client for past and present alcohol, tobacco, prescription drug, OTC drug, and illicit drug use

a 25 year old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit.. she tells the nurse "please let me go! i must leave bc the secret police are after me".. which response is best for the nurse to make - No one is after you, you're safe here. - You'll feel better after you have rested. - I know you must feel lonely and frightened. - Come with me to your room and I will sit with you.

come with me to your room and i will sit with you: this is the best response bc it offers support without judgement or demands

a homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit.. which lab finding obtained on admission is most important for the nurse to report to the HCP - Decreased thyroid stimulating hormone level. - Elevated liver function profile. - Increased white blood cell count. - Decreased hematocrit and hemoglobin levels.

decreased thyroid stimulating hormone level: hyperthyroidism causes an increased level of serum thyroid hormones (T3 and T4), which inhibit the release of TSH, so the clients manic behavior may be related to an endocrine disorder.. elevated liver function profile, increased WBC count, and decreased hematocrit and hemoglobin levels are abnormal findings that are commonly found in the homeless population because of poor sanitation, poor nutrition, and the prevalence of substance abuse

a client on the mental health unit reports concerns about weight gain as a result of taking divalproex (Depakote) and requests assistance to fill out a menu.. the nurse should initiate a referral to which health care team

dietician: the nurse should ask for a referral to the dietician who can assist the client with meal planning for weight reduction

a woman brings her 48 year old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse.. she states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities.. the nurse knows that these behaviors are often associated with A. Dissociative disorderB. Obsessive-compulsive disorderC. Panic disorderD. Post-traumatic stress syndrome

dissociative disorder: sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from ones consciousness, which is the definition of a dissociative disorder

the nurse is assessing a client who is believed to have a borderline personality disorder.. which question is most important to include in this assessment - At what age did you begin to exhibit symptoms? - Do you have a family history of borderline disorder? - How often do you drink alcoholic beverages? - Do you frequently have temper tantrums?

do you frequently have temper tantrums: those with borderline personality disorder demonstrate intense outbursts of anger, so this is the most important question to ask

a nurse is teaching a female client who is in a homosexual relationship about womens health.. which topic is the most important for the nurse to address A. Sexually transmitted diseases.B. Annual gynecologic examination.C. Monthly breast self-examination.D. Domestic violence interventions.

domestic violence interventions: since all women, regardless of sexual orientation, are at risk for domestic violence that can be potentially lethal, this is the most important topic for the nurse to address

a 35 year old male client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal his clothing.. which action should the nurse implement - Encourage the client to actively participate in assigned activities on the unit. - Place a lock on the client's closet. - Ignore the client's paranoid ideation to extinguish these behaviors. - Explain to the client that his suspicions are false.

encourage the client to actively participate in assigned activities on the unit: diverting the clients attention from paranoid ideation and encouraging him to complete assignments can be helpful in assisting him to develop a positive self image

a client is responding to auditory hallucinations and shakes a fist at a nurse and says "back off witch!".. the nurse follows the client into the day room.. what action should the nurse implement

ensure that there is physical space between the nurse and client: personal space needs increase when a client feels anxious and threatened, so adequate social space (4-12 ft) between the nurse and the client should be maintained to minimized the clients escalation

a female client with bipolar disorder, manic phase, is planning weekend activities with the other clients on the unit.. the client interrupts the group, insists that they change their plans to a disco party, and begins to curse loudly when the group refuses to change the plans.. which intervention should the nurse implement

escort the client to a quieter place: a client in the manic phase has an inflated ego, feelings of grandiosity, and is unlikely to respond to limit setting.. to curtail further escalation and disruption, the client should be escorted to a less stimulating environment

which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit

establish rapport in each phase of the nurse client relationship: a client with whom the nurse establishes rapport during the initial interview and in each phase of the nurse client relationship feels understood by the nurse and is more likely to cooperate and provide feedback during the admission process

a client is receiving substitution therapy during withdrawal from benzodiazepines. which expected outcome statement has the highest priority when planning nursing care - Client will not demonstrate cross-addiction. - Codependent behaviors will be decreased. - Excessive CNS stimulation will be reduced. - Client's level of consciousness will increase.

excessive CNS stimulation will be reduced: substitution therapy with another CNS depressant is intended to decrease the excessive CNS stimulation that can occur during benzodiazepine withdrawal

a female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped.. the nurse determines the client is in the acute phase of rape trauma syndrome.. what action should the nurse implement first A. Secure samples of vaginal hair combings.B. Offer prophylactic antibiotic medication.C. Explain the rape protocol to the client. D. Implement crisis intervention counseling.

explain the rape protocol to the client: impact reactions of the acute phase of the rape trauma syndrome include shock, emotional numbness, confusion, disbelief, restless, and agitated motor activity, so explanation of the forensic rape protocol and permission to proceed with examination should be provided first to minimize additional trauma during assessment and the collection of evidence.. after the collection of evidence, prophylactic antibiotic medication is provided and then crisis intervention counseling intitiated

a male client who is on the liver transplant list is called to the unit for a possible transplant.. when learning that the donor organ is no longer available, the client slams doors and shouts vulgarities about his situation.. what action should the nurse implement first - Encourage him to share his feelings more appropriately - Express concern over his disappointment - Arrange to have a clergy person visit - Administer a PRN prescription for an anxiety drug

express concern over his disappointment: addressing the clients disappointment enables the client to express feelings of frustration in a safe environment

while assessing a 70 year old male client, a nurse working in the outpatient clinic notices bruises on the clients chest.. the client admits that his daughter, who is is caregiver, becomes frustrated and sometimes hits him.. what is the priority outcome for the elderly client who sustained the abuse A. Verbalizes an acceptance of health status.B. Expresses his feelings of satisfaction with care. C. States that the frequency of abuse has decreased.D. Describes the potential danger of his situation.

expresses his feelings of satisfaction with care: abuse cessation should result in the client feeling satisfied with his care

the nurse should hold the next scheduled dose of a clients haloperidol (Haldol) based on which assessment finding A. Dizziness when standing. B. Shuffling gait and hand tremors.C. Urinary retention.D. Fever of 102 F

fever of 102: a fever may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antiopsychotics.. the HCP should be contacted before administering the next dose of Haldol

a client who is diagnosed with schizophrenia is admitted to the hospital.. the nurse assesses the clients mental status.. which assessment finding is most characteristic of a client with schizophrenia A. Mood swings. B. Extreme sadness.C. Manipulative behavior.D. Flat affect.

flat affect: disinterest, and diminished or lack of facial expression is characteristic of schizophrenia and is referred to as a flat affect

the nurse is planning the care for a client based on the psychoanalytical model.. which intervention should the nurse include A. Emphasize the client's strengths and assets.B. Teach the importance of medication compliance. C. Offer the client psychoeducational materials to read.D. Focus on the client's positive or negative feelings toward the nurse.

focus on the clients positive or negative feelings toward the nurse: interactions and interventions that focus on the clients positive or negative feelings toward the nurse are based on the psychoanalytical model of mental health care

the nurse is caring for a client who was admitted for alcohol detoxification 2 days ago.. which finding is most critical for the nurse to report to the HCP

global confusion and inability to recognize family members: delirium tremens (DT) or alcohol withdrawal delirium usually peaks 2-3 days (48-72 hrs) after cessation or reduction of intake (although it can occur later) and lasts 2-3 days.. the risk of DT carries a 2-5% mortality rate, so this critical syndrome of alcohol withdrawal, manifested by global confusion and an inability to recognize family members is life threatening and requires emergency medical intervention

an adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move.. which response is best for the nurse to provide - You are in the hospital, and I am the nurse caring for you. - It must be difficult for you to control your anxious feelings. - Go to occupational therapy and start a project. - You are not in a war area now; this is the United States.

go to occupational therapy and start a project: delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others.. delusions are often well-fixed, and though saying "you are in a hospital, and i am the nurse caring for you" reinforces reality, it is argumentative and dismisses the clients fears.. it is often difficult for the client to recognize the relationship between delusions and anxiety ("it must be difficult for you to control your anxiety"), and the nurse should reassure the client that he is in a safe place.. dismissing delusional thinking ("you are not in a war now, this is the US"), is unrealistic bc neurochemical imbalances that cause positive symptoms of schizophrenia require antipsychotic drug therapy

during the admission of a male client to the mental health unit, the client tells the nurse that he had a panic attack today and ran out of the physicians office.. which question is most important for the nurse to ask the client

have you had any thoughts of hurting yourself: assessing for suicidal ideation is most essential

a 22 year old male client is admitted to the emergency center following a suicide attempt.. his records reveal that this is his third suicide attempt in the past two years.. he is conscious, but does not respond to verbal commands for treatment.. which assessment finding should prompt the nurse to prepare the client for gastric lavage - He ingested the drug 3 hours prior to admission to the emergency center. - The family reports that he took an entire bottle of acetaminophen (Tylenol). - He is unresponsive to instructions and is unable to cooperate with emetic therapy. - Those with repeated suicide attempts desire punishment to relieve their guilt.

he is unresponsive to instructions and is unable to cooperate with emetic therapy: bc the client is unable to follow instructions, emetic therapy would be very difficult to implement and gastric lavage would be necessary

which action should the nurse implement during the termination phase of the nurse client relationship - help summarize accomplishments - identifying new problem areas - confronting necessary changes - in depth assessment of the client, including past history

help summarize accomplishments: by noting the clients accomplishments, the clients progress and self confidence can be summarized.. the working phase focuses on identifying new problem areas and confronting necessary changes.. the orientation phase includes an in depth assessment of the client, including past history

the nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless.. what is the priority nursing diagnosis A. Impaired mobility.B. Ineffective individual coping.C. Impaired verbal communication.D. High risk for fluid and electrolyte imbalance.

high risk for fluid and electrolyte imbalance: maintaining physiological stability by first addressing basic physiological needs is the priority.. a client who is in a catatonic or stuporous state is at risk for malnutrition and/or dehydration, so risk for fluid and electrolyte imbalance is the priority nursing diagnosis for this client at this time

a male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment.. since he has a dual diagnosis, which person is best for the nurse to refer this client to first - The emergency room nurse. - His case manager. - The clinic healthcare provider. - His support group sponsor.

his case manager: the case manager is responsible for coordinating community services, and since this client has a dual diagnosis, this is the best person to describe available treatment options

a client who has been admitted to the psychiatric unit tells the nurse "my problems are so bad that no one can help me".. which response is best for the nurse to make A. "How can I help?" B. "Things probably aren't as bad as they seem right now."C. "Let's talk about what is right with your life."D. "I hear how miserable you are, but things will get better soon."

how can i help: offering self shows empathy and caring and is the best of the choices provided

a 35 year old married woman works full time in a factory and has been absent from work for three days at a time on several occasions.. each time she returns to work, she wears dark glasses to cover facial bruising.. her supervisor refers her to the occupational health nurse.. what assessment question is most important for the nurse to initially use A. Do you drink excessively?B. Did your husband beat you?C. How did this happen to you? D. What did you do to deserve this?

how did this happen to you: domestic violence can present in several forms, including sexual, physical, mental, and neglect.. the victim of spousal abuse is often frightened of may feel at fault about the abuse, so a therapeutic relationship should be established with the client using non judgmental, open ended questions, so the client is comfortable to disclose details about the injury, if abuse is suspected

which statement made by an adolescent in group therapy should the nurse identify as a priority in planning care

i have a necktie in my room that i can use to hang myself: assessment of suicidal ideations should include the degree of lethality of the method, the individuals access to whatever is needed to carry out the attempt, and the specifics of the plan.. the more detailed the plan, the greater the risk for a successful attempt

which client statement should the nurse identify as most typical of a client with mania

i manage our finances great bc i buy in big quantities: a client with bipolar disorder, mania, characteristically demonstrates thoughts of inflated self esteem, grandiosity, and a tendency for excessiveness, such as excessive spending

a 72 year old female client is admitted to the psychiatric unit with a diagnosis of major depression.. which statement by the client should be of greatest concern to the nurse and require further assessment A. "I will die if my cat dies." B. "I don't feel like eating this morning."C. "I just went to my friend's funeral."D. "Don't yo have more important things to do?"

i will die if my cat dies: sometimes a client will use an analogy to describe themselves and this would be an indication for conducting a suicide assessment

a client on the psychiatric unit appears to imitate a certain nurse on the unit.. the client seeks out this particular nurse and imitates her mannerisms.. the nurse knows that the client is using which defense mechanism A. SublimationB. IdentificationC. IntrojectionD. Repression

identification: identification is an attempt to be like someone or emulate the personality traits of another..sublimation is substituting an unacceptable feeling for one that s more socially acceptable.. introjection is incorporating the values or qualities of an admired person or group into ones own ego structure.. repression is the involuntary exclusion of painful thoughts or memories from ones awareness

the nurse is caring for a female client who is admitted for depression with the nursing diagnosis, self esteem, chronic low.. which client response indicates to the nurse that the client has improved self esteem - identifies own strengths - crying during sessions with a nurse or other members of the health care team - avoid talking about issue - threatening suicide

identifies own strengths: identifying ones personal strengths is an important part of increasing self esteem.. crying during sessions with a nurse or other members of the health care team is a sign of depression or sadness and does not indicate an improved self esteem

the parents of a 14 year old boy bring their son to the hospital.. he is lethargic, but responsive.. the mother states "i think he took some of my pain pills".. during initial assessment of the teenager, what information is most important for the nurse to obtain from the parents A. If he has seemed depressed recently. B. If a drug overdose has ever occurred before.C. If he might have taken any other drugs.D. If he has a desire to quit taking drugs

if he might have taken any other drugs: knowledge of all substances taken will guide further treatment, such as administration of antagonists, so obtaining this information has the highest priority

the nurse plans to help an 18 year old female mentally retarded client ambulate the first postoperative day after an appendectomy.. when the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse "get out of here! ill get up when I'm ready!".. which response is best for the nurse to make A. "Your healthcare provider has prescribed ambulation on the first day postoperative day."B. "You must ambulate to avoid complications which could cause more discomfort than ambulating."C. "I know how you feel. You're angry about having to ambulate, but this will help you get well."D. "I'll be back in 30 minutes to help you get out of bed and walk around the room."

ill be back in 30 min to help you get out of bed and walk around the room: this provides a "cooling off" period, is firm, direct, non-threatening, and avoids arguing with the client

a 38 year old female client is admitted with a diagnosis of paranoid schizophrenia.. when her tray is brought to her, she refuses to eat and tells the nurse, "i know you are trying to poison me with that food".. which response is most appropriate for the nurse to make A. I'll leave your tray here. I am available if you need anything elseB. You are not being poisoned. Why do you think someone is trying to poison you C. No one on this unit has ever died from poisoning. You are safe here.D. I will talk to your healthcare provider about the possibility of changing your diet

ill leave your tray here.. i am available if you need anything else: this is the best response.. the nurse does not argue with the client nor demand that she eat, but offers support by agreeing to "be there if needed" (to warm the food)

a 46 year old female client has been on antipsychotic neuroleptics for the past three days.. she has had a decrease in psychotic behavior and appears to be responding well to the medication.. on the fourth day, the clients blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity.. which action should the nurse initiate A. Place the client on seizure precautions and monitor carefully. B. Immediately transfer the client to ICU.C. Describe the symptoms to the charge nurse and record on the clients chart.D. No action is required at this time as these are known side effects of such drugs.

immediately transfer the client to the ICU: these symptoms are descriptive of neuroleptic malignant syndrome (NMS) which is an extremely serious/life threatening reaction to the neuroleptic drugs.. the major symptoms of this syndrome are fever, rigidity, autonomic instability, and encephalopathy.. respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can result in death.. this is an EMERGENCY situation, and the client requires immediate critical care

the daughter of a female client with stage 1 alzehimers disease asks the nurse what changes should she expect to demonstrate in this stage.. what finding should the nurse tell the daughter is common

inability to recognized ones location: evidence indicates that frequent incidences of confusion, such as being unable to recognize ones location in a familiar environment is associated with the early stages of alzehimers disease

the nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents.. according to erickson, these parents who are adapting to middle adulthood should exhibit which characteristic A. Loss of independenceB. Increased self-understandingC. Isolation from societyD. Development of intimate relationship

increased self understanding: middle adulthood is characterized by self reflection, understanding, and acceptance, and generatively or guidance of children

the nurse is planning discharge for a male client with schizophrenia.. the client insists that he is returning to his apartment, although the HCP informed him that he will be moving to a boarding home.. what is the most important nursing diagnosis for discharge planning A. Ineffective denial relate to situational anxiety.B. Ineffective coping related to inadequate support.C. Social isolation related to difficult interactions.D. Self-care deficit related to cognitive impairment.

ineffective denial related to situational anxiety: the best nursing diagnosis is this bc the client is unable to acknowledge the move to a boarding home

a male client tells the nurse that he plans to kill his spouse and her lover as soon as he is released from the hospital.. what action should the nurse implement A. Keep this information confidential until the client's release.B. Immediately contact the client's spouse and the lover.C. File oral and written reports with the local police department.D. Inform the healthcare provider and document the plan in the record.

inform the HCP and document the plan in the record: the Tarasoff decision gives mental health professionals a duty to warn prospective victims, but the extent and discharge of the duty may vary from state to state.. the HCP should be notified, and the information documented in the clients record

a female client who is admitted for treatment of uncontrolled DM is withdrawn and tearful.. she complains she has gained excessive weight bc she hates her diet, hates taking insulin, and just wants to be normal again.. what therapeutic action should the nurse take A. Assist the client in verbalizing distress about the disease.B. Inquire about emotional factors affecting the client's present condition. C. Assess priorities to be set for the client's overall nursing care plan.D. Encourage the client to emotionally accept the chronicity of the disease.

inquire about emotional factors affecting the clients present condition: holistic care considers biological, psychological, and sociocultural factors that influence ones health status.. the client is giving clues to psychological distress, so assessment for emotional factors that have impacted the clients present condition should be made

the nurse is assessing a clients intelligence.. which factor should the nurse remember during this part of the mental status exam - Acute psychiatric illnesses impair intelligence. - Intelligence is influenced by social and cultural beliefs. - Poor concentration skills suggests limited intelligence. - The inability to think abstractly indicates limited intelligence.

intelligence is influenced by social and cultural beliefs: social and cultural beliefs have significant impact on intelligence.. chronic psychiatric illness may impair intelligence, especially if it remains untreated.. limited concentration does not suggest limited intelligence.. difficulties with abstractions are suggestive of psychotic thinking, not limited intelligence

when assessing a clients emotional intelligence, which client capabilities should the nurse focus the interview on with a client diagnosed with a chronic mental illness

interpersonal and intrapersonal skills: interpersonal and interpersonal intelligence form ones personal intelligence or emotional quotient, so the nurse should focus inquiries on social skills

the wife of a male client recently diagnosed with schizophrenia asks the nurse, "what exactly is schizophrenia? is my husband all right?".. which response is best for the nurse to provide A. It sounds like you're worried about your husband. Let's sit down and talkB. It is a chemical imbalance in the brain that causes disorganized thinkingC. Your husband will be just fine if he takes his medication regularlyD. I think you should talk to your husband's psychologist about this question

it is a chemical imbalance in the brain that causes disorganized thinking: the nurse should answer the clients question with factual information and explain that schizophrenia is a chemical imbalance in the brain

which nursing intervention should the nurse implement with parents who experience a fetal demise and express the wish not to see the baby A. Tell them there is nothing to fear.B. Insist that they hold infant so they can grieve.C. Respect their wishes and release the body to the morgue.D. Keep the body available for a few hours in case they change their minds.

keep the body available for a few hours in case they change their minds: grieving parents should be encouraged to hold their infant after death to facilitate closure.. if parents are hesitant about seeing or holding their dead infant, the fetus should be available for a few hours in the event they change their mind after the initial shock

when preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), it is most important for the nurse to include which instruction A. "It may take 3 to 4 weeks to achieve therapeutic effects." B. "Keep our dietary salt intake consistent."C. "Avoid eating aged cheese and chicken liver."D. "Eat foods high in fiber such as whole grain breads."

keep your dietary salt intake consistent: lithiums effectiveness is influenced by salt intake.. too much salt causes more lithium to be excreted, thereby decreasing the effectiveness of the drug.. too little sad causes less lithium to be excreted, potentially resulting in toxicity

a male client is admitted to a mental health unit on friday afternoon and is very upset on sunday because he has not had the opportunity to talk with the HCP.. which response is best for the nurse to provide this client - Let me call and leave a message for your healthcare provider. - The healthcare provider should be here on Monday morning. - How can I help answer your questions? - What concerns do you have at this time?

let me call and leave a message for your HCP: it is best for the nurse to call the HCP bc clients have the right to information about their treatment

an 86 year old female client with alzheimers disease is wandering the busy halls of the extended care facility and asks the nurse "where should i stand for the parade".. which response is best for the nurse to provide A. Anywhere you want to stand as long as you don't get hurt by those in the paradeB. You are confused because of all the activity in the hall. There is no parade C. Let's go back to the activity room and see whats going on in thereD. Remember I told you that this is a nursing home and I am your nurse

let us go back to the activity room and see what is going on in there: it is common for those with alzheimers disease to use the wrong words.. redirecting the client (using an acceptable non judgmental dialogue) to a safer place and familiar activities is most helpful bc client experience short term memory loss

a 35 year old male client on the psychiatric ward of a general hospital believes that someone is trying to poison him.. the nurse understands that a clients delusions are most likely related to his A. Early childhood experiences involving authority issues. B. Anger about being hospitalized.C. Low self-esteemD. Phobia fear of food

low self esteem: psychotic clients have difficulty with trust and have low self esteem.. nursing care should be directed at building trust and promoting positive self esteem.. activities with limited concentration and no competition should be encouraged in order to build self esteem

the charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed.. what is the most important intervention to implement during the first 48 hours after the clients admission to the unit A. Monitor appetite and observe intake at meals. B. Maintain safety in the client's milieu.C. Provide ongoing, supportive contact.D. Encourage participation in activities.

maintain safety in the clients milieu: the most important reason for closely observing a depressed client immediately after admission is to maintain safety, since suicide is a risk with depression

the community health nurse talks to a male client who has bipolar disorder.. the client explains that he sleeps 4-5 hours a night and is working with his partner to start two new businesses and build an empire.. the client stopped taking his meds several days ago.. what nursing problem has the highest priority A. Excessive work activity. B. Decreased need for sleep.C. Medication management.D. Inflated self-esteem.

medication mgmt: the most important nursing problem is medication mgmt because compliance with the medication regimen will help prevent hospitalization

a nurse working on a mental health unit receives a community call from a person who is tearful and states "i just feel so nervous all of the time.. i don't know what to do about my problems.. i havent been able to sleep at night and have hardly eaten for the past 3-4 days".. the nurse should initiate a referral based on which assessment A. Altered thought processes B. Moderate levels of anxiety.C. Inadequate social support.D. Altered health maintenance.

moderate levels of anxiety: the nurse should initiate a referral based on anxiety levels and feelings of nervousness that interfere with sleep, appetite, and the inability to solve problems

the nurse is caring for a client who received the first time ECT a half hour ago.. which action should the nurse implement first A. Offer oral fluids.B. Monitor vital signs. C. Evaluate ECT effectiveness.D. Encourage group participation.

monitor VS: sedatives, muscle relaxants, and an anticholinergic agent are often prescribed for the client during ECT.. VS should be monitored during recovery after the ECT procedure

the nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit.. which complaint related to administration of this drug should the nurse expect this client to make A. "My mouth feels like cotton." B. "That stuff gives me indigestion."C. "This pill gives me diarrhea."D. "My urine looks pink."

my mouth feels like cotton: a dry mouth is an anticholinergic effect that is an expected SE of MAOIs such as phenelzine sulfate (Nardil)

a client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness.. what action should the nurse take A. Notify the healthcare provider. Immediately and prepare for administration of an antidoteB. Notify the healthcare provider of the symptoms prior to the next administration of the drug C Record the symptoms as normal side effects and continue administration of prescribed dosage. D. Hold the medication and refuse to administer additional amount of the drug

notify the HCP of the symptoms prior to the next administration of the drug: early SE of lithium carbonate (occurring with serum lithium levels below 2.0) generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness, and muscular weakness.. at higher levels, ataxia, tinnitus, blurred vision, and large dilute urine output may occur

the nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home.. which statement is most indicative of the need for careful follow up after discharge A. "Crickets are a good course of protein." B. "I have no heard any voices for a week."C. "Only my belief in God can help me."D. "Sometimes I have a hard time sitting still."

only my belief in God can help me: the most frequent cause of increased symptoms in psychotic clients is non compliance with the medication regimen.. if clients believe that "god alone" is going to heal them then they may discontinue their medication

a 45 year old male client tells the nurse that he used to believe that he was jesus christ, but now he knows he is not.. which response is best for the nurse to make A. Did you really believe you were Jesus Christ?B. I think you're getting wellC. Others have had similar thoughts when under stressD. Why did you think you were Jesus Christ?

others have had similar thoughts when under stress: this response offers support by assuring the client that others have suffered as he has (also the principle on which AA acts)

a client with panic disorder tells the nurse, "this illness is awful, I'm frightened that i will always be this way and that theres no hope for me".. what is the best information for the nurse to provide A. Panic disorder is treatable in a number of different ways, including medication. B. Understanding the fact that a cure is not attainable helps the client learn to adjust.C. This disorder is a biologically determined hereditary disease that has no cure.D. Evidence based practice indicates that neuroleptic drugs can be used prophylactically.

panic disorder is treatable in a number of different ways, including medication: to foster the clients ability cope, effective treatment options for panic disorder, such as desensitization, cognitive restructuring, relaxation, and psychotropic medications should be discussed

on admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television.. twenty four hours after admission, the nurse notes that the client is withdrawn and isolated.. it is best for the nurse to encourage this client to become involved in which activity A. Clean the unit kitchen cabinetsB. Participate in a group quilting projectC. Watch television in the activity roomD. Bake a cake for a resident's birthday

participate in a group quilting project: peer interaction in a group activity will help to prevent social isolation and withdrawal

the nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms - Permit rest periods as needed. - Speaking slowly and simply. - Place the client on suicide precautions. - Observe and encourage food and fluid intake. - Encourage vigorous exercise and long walks on the unit. - Allow the client extra time to compete tasks

permit rest periods as needed, speaking slowly and simply, allow the client extra time to compete tasks, observe and encourage food and fluid intake, encourage mild exercise and short walks on the unit: these should be included in this clients plan of care bc these measures promote the clients comfort and well being.. neurovegetative symptoms accompany the mood disorder of depression and include physiological disruptions, such as anorexia, constipation, sleep disturbance, and psychomotor retardation

which action should the nurse implement first for a client experiencing alcohol withdrawal A. Apply vest or extremity restraints.B. Give an alpha-adrenergic blocker.C. Provide a diet high in protein and calories.D. Prepare the environment to prevent self-injury.

prepare the environment to prevent self injury: self destructive or violent behavior provides a potentially immediate and life threatening risk to the client and others, so a safe environment should be provided by removing any potential objects that could inflict self injury

a child is brought to the emergency room with a broken arm.. bc of other injuries, the nurse suspects the child may be a victim of abuse.. when the nurse tries to give the child an injection, the childs mother becomes very loud and shouts "i won't leave my son! don't you touch him! you'll hurt my child!".. what is the best interpretation of the mothers statements.. the mother is A. Regressing to an earlier behavior patternB. Sublimating her angerC. Projecting her feelings onto the nurseD. Suppressing her fear

projecting her feelings onto the nurse: projection is attributing ones own thoughts, impulses, or behaviors onto another-- it is the mother who is probably harming the child and she is attributing her actions to the nurse

a 27 year old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase.. she is demanding and active.. which intervention should the nurse include in this clients plan of care A. Schedule her to attend various group activities.B. Reinforce her ability to make her own decisions.C. Encourage her to identify feelings of anger.D. Provide a structural environment with little stimuli.

provide a structured environment with little stimuli: clients in the manic phase of a bipolar disorder require decreased stimuli and a structured environment

a male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry, and belittles the nurses.. while a nurse is changing the dressing over a laceration, the client screams "don't touch me! your so stupid that you'll make it worse!".. which intervention is best for the nurse to implement A. Leave the room without saying a word.B. Provide information about infection prevention.C. Allow the client to change the dressing himself.D. Explain the healthcare provider's prescription.

provide information about infection prevention: several factors impact a client with anger, which is a cognitively driven problem.. the correct nursing intervention helps the client test cognition and may lead to lowering anger which impacts the clients readiness for acceptance of the nurses interventions in providing care.. since the dressing change is initiated, making the client aware of why the dressing change is necessary is therapeutic to forming a relationship.. the feelings of powerlessness that are currently being expressed through anger only escalate if the nurse offers no alternatives to addressing the presenting issues

a female client responds to the nurse with negative comments and antagonistic behavior.. the nurse tells the client that she is unconsciously casting the nurse in the role of the clients mother.. the nurses feedback is based on which model of therapy A. Medical.B. Existential.C. Interpersonal.D. Psychoanalytical.

psychoanalytical: the psychoanalytical model uses concepts that interpret and focus on working through previously unresolved conflicts.. the medical model focuses the diagnosis of a mental illness and its subsequent treatments, such as somatic treatments, pharmacotherapy, and ECT..the existential model focuses on the persons experience in the here and now, with much less attention focused on the persons past.. the interpersonal model focuses on the belief that behavior evolves around interpersonal relationships

on admission, a highly anxious client is described as delusional.. the nurse understands that delusions are most likely to occur with which class of disorder A. Neurotic B. PersonalityC. AnxietyD. Psychotic

psychotic: delusions are false beliefs associated with psychotic behavior, and psychotic persons are not in touch with reality

during an inpatient therapy group session, a client tells the members that he hears voices that say his doctor is going to poison him.. he continues " i look around to see who's talking to me, and i can't see anybody".. another client replies "i used to hear voices, too.. i found out they were my imagination.. the voices you hear aren't real either".. which phenomenon, common to groups, is exemplified in this interchange - ventilation - universality - reality testing - interpersonal learning

reality testing: reality testing is a process in which an individual validates ones own perception of reality.. group members can provide reality testing by monitoring each members reactions and behaviors and providing feedback in an open and nonthreatening manner

a female client refuses to take an oral hypoglycemic agent bc she believes that the drug is being administered as part of an elaborate plan by the mafia to harm her.. which nursing intervention is most important to include in this clients plan of care - Reassure the client that no one will harm her while she is in the hospital. - Ask the healthcare provider to give the client the medication - Explain that the diabetic medication is important to take. - Reassess client's mental status for thought processes and content.

reassess clients mental status for thought processes and content: the most important intervention is to reassess the clients mental status and to take further action based on findings of this assessment

a client with bipolar disorder on the mental health unit becomes loud, and shouts at one of the nurses "you fat tub of lard! get something done around here!".. what is the best initial action for the nurse to take A. Have the orderly escort the client to his room. B. Tell the client his healthcare provider will be notified if he continues to be verbally abusive.C. Redirect the client's energy by asking him to tidy the recreation room.D. Call the healthcare provider to obtain a prescription for a sedative.

redirect the clients energy by asking him to tidy the recreation room: distracting the client, or redirecting his energy prevents further escalation of the inappropriate behavior

what action should the nurse take when a client who is psychotic proposes goals that are both unrealistic and undesirable A. Do nothing and remember the client's rights.B. Express doubt that the goal can be achieved.C. Tell the client that the goal is unrealistic.D. Reflect the client's behavior and its consequences.

reflect the clients behavior and its consequences: a client who is psychotic is unable to visualize the consequences of proposed goals, so the use of reflection about the clients behavior and its consequences is the most therapeutic approach

a woman admitted to the ED is bleeding profusely from a patch where hair was lost from her scalp.. she is accompanied by her husband who tells the nurse that his wife caught her hair on the railing and pulled it out when she fell down the stairs.. the husband is solicitous of his wife and quickly answers questions on her behalf.. he attempts to comfort his wife by saying to her "i am right here with you dear, nothing can keep us apart".. what is the priority nursing intervention A. Notify the local police of a suspected spousal abuse situation.B. Ask the hospital security to remove the husband from the treatment room.C. Reassure the husband that his wife will be treated well while he is in the waiting area.D. Require the husband to leave the cubicle while the client is being treated.

require the husband to leave the cubicle while the client is being treated: the client should be questioned about the possibility of spousal abuse and cannot answer truthfully in the presence of the perpetrator, so separating the couple is a priority, and this action is the best method of providing this separation

a client is scheduled to complete a positron emission tomography (PET) scan.. the client asks the nurse to explain the reason the test was prescribed.. how should the nurse respond A. Images indicate the presence of tumors and scars.B. The scan clearly outlined structures of the brain.C. Results show activity in various portions of the brain. D. PET shows biochemical levels of neurotransmitters.

results show activity in various portions of the brain: the results of a PET scan (used to detect cerebral activity in depression, schizophrenia, and alzheimers disease) shows brightly colored cerebral areas where an accumulation of a radioactivity tagged glucose is used as a tracer to visualize brain activity, blood flow, and glucose metabolism

a male client is admitted to the mental health unit bc he was feeling depressed about the loss of his wife and job.. the client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago.. VS are T 100, P 100, BP 142/100.. the nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis A. Risk for injury related to suicidal ideation.B. Risk of injury related to alcohol detoxification.C. Knowledge deficit related to ineffective coping.D. Health seeking behaviors related to personal crisis.

risk for injury related to alcohol detoxification: the most important nursing diagnosis is related to alcohol detoxification bc the client has elevated VS, a sign of alcohol detoxification

which diet selection by a client who is depressed and taking the MAOI tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen - Hamburger, French fries, and chocolate milkshake. - Liver and onions, broccoli, and decaffeinated coffee. - Pepperoni and cheese pizza, tossed salad, and a soft drink. - Roast beef, baked potato with butter, and iced tea.

roast beef, baked potato with butter, and iced tea: this meal contains no tyramine.. tyramine in foods interacts with MAOIs in the body causing a hypertensive which is life threatening, and Parnate is classified as an MAOI antidepressant

the nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but have no context or relationship with one topic to the next in the conversation. this clients behavior and thought processes are consistent with which syndrome A. Dementia B. Depression C. Schizophrenia D. Chronic brain syndrome

schizophrenia: the client is demonstrating symptoms of schizophrenia, such as disorganized speech that may include word salad (communication that includes both real and imaginary words in no logical order), incoherent speech, and clanging (rhyming).. dementia is a global impairment of intellectual (cognitive) functions that may be progressive, such as alzheimers or organic brain syndrome.. depression is typified by psychomotor retardation, and the client appears to be slowed down in movement, in speech, and would appear listless and disheveled

a 30 year old sales manager tells the nurse "i am thinking about a job change. i don't feel like i am living up to my potential." which of maslows developmental stages is the sales manager attempting to achieve A. Self-Actualization B. Loving and Belonging C. Basic Needs D. Safety and Security

self actualization: self actualization is the highest level of maslows developmental stages, which is an attempt to fulfill ones full potential.. loving and belonging is identifying support systems.. basic needs is the first level of maslows developmental stages and is the foundation upon which higher needs rest.. individuals who feel safe and secure in their environment perceive themselves as having physical safety and lack fear of harm

during a one to one interaction, a male client describes the sadness he experienced when his mother died.. suddenly, the nurse begins to think about her grandmothers death.. as a result, the nurse asked the client to describe his thoughts when he learned of his own mothers illness.. what is the nurse doing

self awareness: self awareness defines the nurses awareness of his or her own feelings while empathizing with the client

a 40 year old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission.. he reports he has no family that cares about him and was living on the streets prior to this admission.. according to ericksons theory of psychosocial development, which stage is the client in at this time - Isolation. - Stagnation. - Despair. - Role confusion.

stagnation: the client is in ericksons generativity vs. stagnation stage (ages 24-45), and meeting the task includes maintaining intimate relationships and moving toward developing a family

a male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon.. when the nurse asks the teen to identify his reason for the assault, he replies "bc he made me mad!".. which goal is best for the nurse to include in the clients plan of care.. the client will - Teach the client to outline methods for managing anger. - Suggest actions to control impulsive responses toward self and others. - Encourage client to verbalize feelings when anger occurs. - Discuss recognizing consequences for behaviors exhibited.

suggest actions to control impulsive actions toward self and others: those with bipolar disorder often exhibit poor impulse control, and the most important goal for this client at this time is to learn to control impulsive behavior so that he can avert the social consequences related to such behaviors

a 19 year old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit.. what action should the nurse take A. Encourage the client self-motivation by asking her to pass trays for the rest of the week. B. Provide an additional challenge by asking the client to help feed the older clients.C. Suggest another way or this client to participate in the unit's activities.D. Tell the client that hospital guidelines allow only staff to pass the trays.

suggest another way for this client to participate in unit activities: anorexics gain pleasure from providing others with food and watching them eat.. such behaviors reinforce their perception of self control.. these clients should not be allowed to plan or prepare food for unit activities and their desires to do so should be redirected

what nursing assessment is the priority focus for a client with major depression A. Mood and affect.B. Suicidal ideation. C. Nutritional status.D. Fluid and electrolyte balance.

suicidal ideation: suicidal ideation is a major risk factor in a client with major depression

a client who is admitted with the chief complaint of feeling depressed tells the nurse, i want to feel normal again.. how should the nurse respond

tell me more about how things are with you: when a client offers psycho-emotional complaints as the reason for admission, open-ended statements that seek clarification and elaboration provide the nurse with information about the clients life experiences that helps the nurse empathize, establish rapport, and support the client while reexamining and expressing feelings

physical exam of a 6 year old reveals several bite marks in various locations on his body.. x-ray exam reveals healed fractures of the ribs.. the mother tells the nurse that her child is always having accidents.. which initial response by the nurse would be most appropriate A. I need to inform the health care provider about your child's tendency to be accident prone. B. Tell me more specifically about your child's accidentsC. I must report these injuries to the authorities because they do not seem accidental. D. Boys this age always to require more supervision and can be quite accident prone.

tell me more specifically about your childs accidents: seek more information using an open ended, non threatened statement

an elderly female client with advanced dementia is admitted to the hospital with a fractured hip.. the client repeatedly tells the staff "take me home.. i want my mommy".. which response is best for the nurse to provide - Orient the client to the time, place, and person. - Tell the client that the nurse is there and will help her. - Remind the client that her mother is no longer living. - Explain the seriousness of her injury and need for hospitalization

tell the client that the nurse is there and will help her: those with dementia often refer to home or parents when seeking security and comfort.. the nurse should use the techniques of "offering self" and "talking to the feelings" to provide reassurance.. clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information

a female client comes to an outpatient therapy appointment intoxicated.. the spouse tells the nurse, "there wasn't anything i could do to stop her drinking this morning".. what intervention should the nurse take at this time A. Tell the client that therapy cannot take place while she is intoxicated.B. Arrange for emergency admission to a detoxification unit.C. Talk to the spouse about strategies to limit the client's drinkingD. Have the client admitted to the inpatient psychiatric unit

tell the client that therapy cannot take place while she is intoxicated: therapy sessions are designed to confront the issues that the client with alcohol dependence may be experiencing.. if the client presents inebriated, a therapeutic and confrontational meeting cannot occur bc the clients judgement is altered

a male client with schizophrenia tells the nurse that the voices he hears are saying "you must kill yourself".. to assist the client in coping with these thoughts, which response is best for the nurse to provide A. Tell yourself that the voices are unreasonableB. Exercise when you hear voicesC. Talk to someone when you hear the voicesD. The voices aren't real, so ignore them

tell yourself that the voices are unreasonable: the nurse should teach the client to use self talk to disprove the voices

which client outcome indicates improvement for a client who is admitted with auditory hallucinations A. Argues with the voices.B. Tells when voices decrease. C. Follows what the voices say.D. Tells the nurse what the voices say.

tells when the voices decrease: hallucinations are defined as false sensory perceptions, and the goal of nursing intervention with clients who are hallucinating is to help them to increase awareness of their symptoms and distinguish between the world of psychosis and reality

a client actively involved in substance addiction therapy frequently relapses into benzodiazepines and alcohol use.. the client tells the nurse, i don't think i will ever be able to kick this habit.. how should the nurse respond

the client must participate in making decisions about his/her own physical and mental health: the client has the right to self determination and the responsibility to make a decision to pursue health or illness, so the client must actively participate

a female client with severe depression is given information about risks, benefits, alternatives, and expected outcomes of ECT and signs the informed consent for treatment.. after the clients family leaves, the client tells the nurse, i signed the papers bc my husband told me i will be deported if my depression is not cured.. what information should the nurse report to the HCP

the clients consent may have been coerced: informed consent requires that the choice is freely given.. although the staff acted ethically and observed the clients right to give informed consent, the decision may have been coerced based family pressure

based on non compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl to IM fluphenazine decanoate.. what is most important to teach the client and family about this change in medication regimen - Signs and symptoms of extrapyramidal effects (EPS). - Information about substance abuse and schizophrenia. - The effects of alcohol and drug interaction. - The availability of support groups for those with dual diagnoses.

the effects of alcohol and drug interaction: alcohol enhances the EPS SE of prolixin.. the half life of prolixin PO is 8 hours, whereas the half life of prolixin decanoate IM is 2-4 weeks.. that means the SE of drinking alcohol are far more severe when the client drinks alcohol after taking the long acting prolixin decanoate IM

a nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse.. which statement most accurately describes the nurses responsibility in cases of suspected child abuse A. The nurse should obtain objective data such as x-rays before reporting suspicions to authorities B. The nurse should confirm any suspicions of child abuse with the health care provider before reporting to the authorities. C. The nurse should report any case of suspected child abuse to the charge nurseD. The nurse should note in the client's record any suspicions of child abuse so that a history of suspicions can be tracked.

the nurse should report any case of suspected child abuse to the nurse in charge: it is the nurses legal responsibility to report all suspected cases of child abuse.. notifying the charge nurse starts the legal reporting process

the nurse suspects child abuse when assessing a 3 year old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns.. which parental behavior provides the greatest validation for such suspicions - The parents' explanation of how the burns occurred is different from the child's explanation of how they occurred. - The parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed any problem. - The parents become very anxious when the nurse suggests that the child may need to be admitted for further evaluation. - The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.

the parents tell the nurse that the child was burned in a house fire which is incompatible with the nurses observation of the type of burn: this provides the most validation.. the parents explanation (subjective data) is incompatible with the objective data (small round burs on the legs and trunk)

which statement about contemporary mental health nursing practice is accurate A. There is one approved theoretical framework for psychiatric nursing practiceB. Psychiatric nursing has yet to be recognized as a core mental health disciplineC. Contemporary practice of psychiatric nursing is primarily focused on inpatient care.D. The psychiatric nursing client may be an individual, family, group, organization, or community

the psychiatric nursing client may be an individual, family, group, organization, or community: mental health nursing is not only concerned with one on one interactions.. psychiatric stressors can impact and be reflected in the overall direction, activities, and responses involving families, groups, and entire communities

a female client with depression attends group and states that she sometimes misses her medication appointments bc she feels very anxious about riding the bus.. which statement is the nurses best response - Can your case manager take you to your appointments? - Take your medication for anxiety before you ride the bus. - Let's talk about what happens when you feel very anxious. - What are some ways that you can cope with your anxiety?

what are some ways that you can cope with your anxiety: the best response is to explore ways for the client to cope with anxiety.. the nurse should encourage problem solving rather than dependence on the case manager for transportation

the nurse observes a female client with schizophrenia watching the news on TV.. she begins to laugh softly and says, "yes my love ill do it".. when the nurse questions the client about her comment she states, "the news commentator is my lover and he speaks to me each evening.. only i can understand what he says".. what is the best response for the nurse to make - What do you believe the news commentator said to you? - Let's watch news on a different television channel. - Does the news commentator have plans to harm you or others? - The news commentator is not talking to you.

what do you believe the news commentator said to you: it is imperative that the nurse determine what the client believes she heard.. the idea of reference may be to hurt herself or someone else, and the main function of a psychiatric nurse is to maintain safety

a male client with schizophrenia who is taking fluphenazine decanoate (prolixin decanoate) is being discharged in the morning.. a repeat dose of medication is scheduled for 20 days after discharge.. the client tells the nurse that he is going on vacation in the bahamas and will return in 18 days.. which statement by the client indicates a need for health teaching A. "When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection." B. "While I am on vacation and when I return, I will not eat or drink anything that contains alcohol."C. "I will notify the healthcare provider if I have a sore throat or flu-like symptoms."D. "I will continue to take my benztropine mesylate (Cogentin) every day."

when i return from my tropical island vacation, i will go to the clinic to get my prolixin injection: photosensitivity is a SE of prolixin and a vacation in the bahamas (with its tropical island climate) increases the clients chance of experiencing this SE.. he should be instructed to avoid direct sun and wear sunscreen

at the first meeting of a group of older adults at a day care center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group.. the older woman shrugs her shoulders and says "you tell me, you're the leader".. what is the best response for the nurse to make A. "Yes I am the leader today. Would you like to be the leader tomorrow."B. "Yes, I will be leading this group. What would you like to accomplish during this time."C. "Yes, I have been assigned to be the leader of this group. I will be here for the next 6 weeks.D. "Yes, I am the leader. You seem angry about not being the leader yourself."

yes i will be leading this group.. what would you like to accomplish during this time: anxiety over participation in a group and testing of the leader characteristically occur in the initial phase of group dynamics.. this response provides information and focuses the group back to defining its function

a client is pacing in the hall near the nurses station and swearing loudly.. what response is best for the nurse to provide A. Hey, what's going on?B. Others are being distracted. Please, quiet down.C. You seem pretty upset. Tell me about it. D. Please go to your room to get control of yourself.

you seem pretty upset.. tell me about it: a client who is distressed and acting out angrily should be assessed for additional information about what may be causing a change in the clients behavior.. therapeutic responses to disruptive behavior or language should begin with the nurses reflective interpretation of the clients distress, and followed with an open ended statement