Mental Health 2

A client diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

a. Risk for injury Although each of the nursing diagnoses listed is appropriate for a client having a manic episode, the priority lies with the client's physiological safety. Hyperactivity and poor judgment put the client at risk for injury.

At a meeting for family members of alcoholics, a spouse says, "I did everything I could to help. I even requested sick leave when my partner was too drunk to go to work." The nurse assesses these comments as what? a. codependence. b. assertiveness. c. role reversal. d. homeostasis

a. codependence. Codependence refers to participating in behaviors that maintain the addiction or allow it to continue without holding the user accountable for his or her actions. The other options are not supported by information given in the scenario.

A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents? (Select all that apply.) a. conveying empathy and acknowledging the child's distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. d. avoiding repetition in what is said to the child. e. staying with the child until the anxiety decreases. f. maximizing opportunities for exercise and play.

a. conveying empathy and acknowledging the child's distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. e. staying with the child until the anxiety decreases. f. maximizing opportunities for exercise and play. The child's symptoms and behavior suggest that he is exhibiting PTSD. Interventions appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the child's distress, repeating content as needed when there is impaired cognitive processing and memory, providing opportunities for comforting and normalizing play and physical activities, correcting any distortion of reality, and staying with the child to increase his sense of security.

A client diagnosed with bipolar disorder who takes lithium carbonate 300 mg three times daily reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with what? a. food. b. an antacid. c. an antiemetic. d. a large glass of juice.

a. food. Some clients find that taking lithium with food diminishes nausea. The incorrect options are less helpful.

A health teaching plan for a client taking lithium should include which instructions? a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of fluid. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine

a. maintain normal salt and fluids in the diet. Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.

A client is experiencing psychomotor agitation associated with major depressive disorder. Which observation presented by the client would the nurse associate with this symptom? a. pacing aimlessly around the room. b. asking the nurse to repeat instructions. c. reporting prickly skin sensations. d. demonstrating slowed verbal responses.

a. pacing aimlessly around the room. Psychomotor agitation may be evidenced by constant pacing and wringing of hands. Slowed movements and responses are aspects of psychomotor retardation. Complaints of the unusual skin sensations may represent a delusion or hallucination. Asking the nurse to repeat instructions indicates difficulty with concentration.

What does the physical assessment of a client diagnosed with bulimia often reveal? a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. 25% underweight.

a. prominent parotid glands. Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and not usually seen in bulimia.

What is the most therapeutic characteristics for a nurse working with a client beginning treatment for alcohol addiction to present? a. Empathetic, supportive b. Skeptical, guarded c. Cool, distant d. Confrontationa

a. Empathetic, supportive Support and empathy assist the client to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase client anxiety and cause the client to cling to defenses

Which suggestions are appropriate for the family of a client diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? (Select all that apply.) a. Limit credit card access. b. Provide a structured environment. c. Encourage group social interaction. d. Supervise medication administration. e. Monitor the client's sleep patterns.

a. Limit credit card access. b. Provide a structured environment. d. Supervise medication administration. e. Monitor the client's sleep patterns. A client with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is over-stimulated by a busy environment. Providing structure helps the client maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. The family should supervise medication administration to prevent deterioration to a full manic episode and because the client is at risk to omit medications.

While the exact cause of bipolar disorder has not been determined; however, what is consistent for most clients? a. several factors, including genetics, are implicated. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. inadequate norepinephrine reuptake disturbs circadian rhythms.

a. several factors, including genetics, are implicated The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.

Which documentation indicates that the treatment plan for a client diagnosed with acute mania has been effective? a. "Converses with few interruptions; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."

a. "Converses with few interruptions; clothing matches; participates in activities." The descriptors given indicate the client is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.

A client diagnosed with anorexia nervosa virtually stopped eating 5 months ago and lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the client is most consistent with the diagnosis? a. "I am fat and ugly." b. "What I think about myself is my business." c. "I'm grossly underweight, but that's what I want." d. "I'm a few pounds' overweight, but I can live with it."

a. "I am fat and ugly." Untreated clients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The client with anorexia will usually tell people perceptions of self. The client with anorexia does not recognize his or her thinness and will persist in trying to lose more weight.

Which assessment made by a client best supports dissociative fugue? a. "I cannot recall why I'm living in this town." b. "I feel as if I'm living in a fuzzy dream state." c. "I feel like different parts of my body are at war." d. "I feel very anxious and worried about my problems."

a. "I cannot recall why I'm living in this town." The client in a fugue state frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited. The distracters are more consistent with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder.

A nurse assesses an individual who commonly experiences anxiety. Which comment by this person indicates the possibility of obsessive-compulsive disorder? a. "I check where my car keys are eight times." b. "My legs often feel weak and spastic." c. "I'm embarrassed to go out in public." d. "I keep reliving a car accident."

a. "I check where my car keys are eight times." Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. Stating "My legs feel weak most of the time" is more in keeping with a somatic disorder. Being embarrassed to go out in public is associated with an avoidant personality disorder. Reliving a traumatic event is associated with posttraumatic stress disorder

What is the priority nursing intervention when caring for a client after an overdose of amphetamines? a. Monitor vital signs. b. Observe for depression. c. Awaken the client every 15 minutes. d. Use warmers to maintain body temperature.

a. Monitor vital signs. An overdose of stimulants, such as amphetamines, can produce respiratory and circulatory dysfunction as well as hyperthermia. Concentration is impaired. This client will be hypervigilant; it is not necessary to awaken the client.

A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? (Select all that apply.) a. "The importance of taking your medication correctly" b. "How to complete an application for employment" c. "How to dress when attending community events" d. "How to give and receive compliments" e. "Ways to quit smoking"

a. "The importance of taking your medication correctly" e. "Ways to quit smoking" Stabilization is maximized by adherence to the antipsychotic medication regimen. Because so many persons with schizophrenia smoke cigarettes, this topic relates directly to the clients' physiological well-being. The other topics are also important but are not priority topics.

A nurse asks a client diagnosed with schizophrenia, "What is meant by the old saying 'You can't judge a book by looking at the cover.'?" Which response by the client indicates concrete thinking? a. "The table of contents tells what a book is about." b. "You can't judge a book by looking at the cover." c. "Things are not always as they first appear." d. "Why are you asking me about books?"

a. "The table of contents tells what a book is about." Concrete thinking refers to an impaired ability to think abstractly. Concreteness is often assessed through the client's interpretation of proverbs. Concreteness reduces one's ability to understand and address abstract concepts such as love or the passage of time. The incorrect options illustrate echolalia, an unrelated question, and abstract thinking

During the third week of treatment, the spouse of a client in a rehabilitation program for substance abuse says, "After this treatment program, I think everything will be all right." Which remark by the nurse will be most helpful to the spouse? a. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol." b. "It will be important for you to structure life to avoid as much stress as you can and provide social protection." c. "Addiction is a lifelong disease of self-destruction. You will need to observe your spouse's behavior carefully." d. "It is good that you are supportive of your spouse's sobriety and want to help maintain it."

a. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol." During recovery, clients identify and use alternative coping mechanisms to reduce reliance on substances. Physical adaptations must occur. Emotional responses were previously dulled by alcohol but are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who need anticipatory guidance and accurate information.

A young adult says, "I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I don't remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them." Which disorders should the nurse suspect based on this history? (Select all that apply.) a. Acute stress disorder b. Depersonalization disorder c. Generalized anxiety disorder d. Post-traumatic stress disorder (PTSD) e. Reactive attachment disorder f. Disinhibited social engagement disorder

a. Acute stress disorder b. Depersonalization disorder d. Post-traumatic stress disorder (PTSD) Acute stress disorder, depersonalization disorder, and PTSD can involve dissociative elements, such as numbing, feeling unreal, and being amnesic for traumatic events. All three disorders are also responses to acute stress or trauma, which has occurred here. The distracters are disorders not evident in this client's presentation. Generalized anxiety disorder involves extensive worrying that is disproportionate to the stressors or foci of the worrying. Reactive attachment disorder and disinhibited social engagement disorder are problems of childhood

An acutely violent client diagnosed with schizophrenia received several doses of haloperidol. Two hours later the nurse notices the client's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine 50 mg IM from the prn medication administration record. b. Reassure the client that the symptoms will subside. Practice relaxation exercises with the client. c. Give trihexyphenidyl 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcut from the prn medication administration record.

a. Administer diphenhydramine 50 mg IM from the prn medication administration record. Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately, so the intramuscular route is best. In this case, the best option given is diphenhydramine.

Which scenario demonstrates a dissociative fugue? a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. b. A man is extremely anxious about his problems and sometimes experiences dazed periods of several minutes passing without conscious awareness of them. c. A woman finds unfamiliar clothes in her closet, is recognized when she goes to new restaurants, and complains of "blackouts" despite not drinking. d. A woman reports that when she feels tired or stressed, it seems like her body is not real and is somehow growing smaller.

a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. The client in a dissociative fugue state relocates and lacks recall of his life before the fugue began. Often fugue states follow traumatic experiences and sometimes involve assuming a new identity. Such persons at some point find themselves in their new surroundings, unable to recall who they are or how they got there. A feeling of detachment from one's body or from the external reality is an indication of depersonalization disorder. Losing track of several minutes when highly anxious is not an indication of a dissociative disorder and is common in states of elevated anxiety. Finding evidence of having bought clothes or gone to restaurants without any explanation for these is suggestive of dissociative identity disorder, particularly when periods are "lost" to the client (blackouts)

A client diagnosed with bipolar disorder commands other clients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select? a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other clients around." d. Honest feedback: "Your controlling behavior is annoying others."

a. Distraction: "Let's go to the dining room for a snack." The distractibility characteristic of manic episodes can assist the nurse to direct the client toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the client or inciting anger. Limit setting and honest feedback may seem heavy-handed and may incite anger.

Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse's response? a. Altruism b. Suppression c. Intellectualization d. Reaction formation

a. Altruism Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and receiving gratification vicariously or from the responses of others. The nurse's reaction is conscious rather than unconscious. There is no evidence of suppression. Intellectualization is a process in which events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing. Reaction formation is when unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite behavior or emotion.

A client diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol, the client is calm. Two hours later the nurse sees the client's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely? a. An acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia

a. An acute dystonic reaction Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis. It appears after prolonged treatment. Waxy flexibility is a symptom seen in catatonic schizophrenia. Internal and external restlessness, pacing, and fidgeting are characteristics of akathisia.

A client in the emergency department shows disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the client? a. An interview room furnished with a desk and two chairs b. A small, empty storage room with no windows or furniture c. A room with an examining table, instrument cabinets, desk, and chair d. The nurse's office, furnished with chairs, files, magazines, and bookcases

a. An interview room furnished with a desk and two chairs Individuals experiencing severe to panic-level anxiety require a safe environment that is quiet, non-stimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the client could cause self-harm, and a small floor space in which the client can move about. A small, empty storage room without windows or furniture would feel like a jail cell. The nurse's office or a room with an examining table and instrument cabinets may be over-stimulating and unsafe

Which nursing intervention has the highest priority for a client diagnosed with bulimia nervosa? a. Assist the client to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore needs for health teaching.

a. Assist the client to identify triggers to binge eating. For most clients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. Often the triggers are anxiety-producing situations. Identification of triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes highest priority.

A client diagnosed with bipolar disorder will be discharged tomorrow. The client is taking a mood stabilizing medication. What is the priority nursing intervention for the client as well as the client's family during this phase of treatment? a. Attending psychoeducation sessions b. Decreasing physical activity c. Increasing food and fluids d. Meeting self-care needs

a. Attending psychoeducation sessions During the continuation phase of treatment for bipolar disorder, the physical needs of the client are not as important an issue as they were during the acute episode. After hospital discharge, treatment focuses on maintaining medication compliance and preventing relapse, both of which are fostered by ongoing psychoeducation.

How do relaxation techniques help clients who have experienced major traumas? a. By engaging the parasympathetic nervous system. b. By increasing sympathetic stimulation. c. By increasing their metabolic rate. d. By releasing hormones

a. By engaging the parasympathetic nervous system. In response to trauma, the sympathetic arousal symptoms of rapid heart rate and rapid respiration prepare the person for flight or fight responses. Afterward, the dorsal vagal response damps down the sympathetic nervous system. This is a parasympathetic response with the heart rate and respiration slowing down and decreasing the blood pressure. Relaxation techniques promote activity of the parasympathetic nervous system.

A child diagnosed with attention deficit hyperactivity disorder (ADHD) will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications? a. CNS stimulants b. Tricyclic antidepressants c. Antipsychotics d. Anxiolytics

a. CNS stimulants CNS stimulants, such as methylphenidate and pemoline, increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with ADHD. The other medication categories listed would not be appropriate.

A nurse plans health teaching for a client diagnosed with generalized anxiety disorder who begins a new prescription for lorazepam. What information should be included? (Select all that apply.) a. Caution in use of machinery b. Foods allowed on a tyramine-free diet c. The importance of caffeine restriction d. Avoidance of alcohol and other sedatives e. Take the medication on an empty stomach

a. Caution in use of machinery c. The importance of caffeine restriction d. Avoidance of alcohol and other sedatives Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving or using machinery and the importance of not using other central nervous system depressants such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special diet. Food will reduce gastric irritation from the medication.

A client admitted to an alcohol rehabilitation program tells the nurse, "I'm actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening." The client is using which defense mechanism? a. Denial b. Projection c. Introjection d. Rationalization

a. Denial Minimizing one's drinking is a form of denial of alcoholism. The Client is more than a social drinker. Projection involves blaming another for one's faults or problems. Rationalization involves making excuses. Introjection involves incorporating a quality of another person or group into one's own personality.

A client diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The client twirls and shadow boxes. The client says gaily, "Do you like my scarves? Here they are my gift to you." How should the nurse document the client's mood? a. Euphoric b. Irritable c. Suspicious d. Confident

a. Euphoric The client has demonstrated clang associations and pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are not the best terms for the client's mood. Suspiciousness is not evident.

A student says, "Before taking a test, I feel very alert and a little restless." Which nursing intervention is most appropriate to assist the student? a. Explain that the symptoms result from mild anxiety and discuss the helpful aspects. b. Advise the student to discuss this experience with a health care provider. c. Encourage the student to begin antioxidant vitamin supplements. d. Listen attentively, using silence in a therapeutic way.

a. Explain that the symptoms result from mild anxiety and discuss the helpful aspects. Teaching about symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety will serve to reassure the client. Advising the client to discuss the experience with a health care provider implies that the client has a serious problem. Listening without comment will do no harm but deprives the client of health teaching. Antioxidant vitamin supplements are not useful in this scenario.

One bed is available on the inpatient eating-disorder unit. A client with which assessment data should be admitted to this bed? a. Going from 150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg b. Going from120 to 90 pounds over a 3-month period. Vital signs are temperature, 36° C; pulse, 50 beats/min; blood pressure 70/50 mm Hg c. Going from110 to 70 pounds over a 4-month period. Vital signs are temperature 36.5° C; pulse, 60 beats/min; blood pressure 80/66 mm Hg d. Going 90 to 78 pounds over a 5-month period. Vital signs are temperature, 36.7° C; pulse, 62 beats/min; blood pressure 74/48 mm Hg

a. Going from 150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, weighs below 75% of ideal body weight, temperature below 36° C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg

Which assessment findings present familial risks for a child to develop a psychiatric disorder? (Select all that apply.) a. Having a mother diagnosed with schizophrenia b. Being the oldest child in a family c. Living with an alcoholic parent d. Being an only child e. Living in an urban community

a. Having a mother diagnosed with schizophrenia c. Living with an alcoholic parent Familial risk factors that correlate with child psychiatric disorders include severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster-care placement. Having a parent with a substance abuse problem increases the risk of marital discord. A family history of schizophrenia presents a genetic risk. Being in a middle-income family, living in an urban community, and being an only or oldest child do not represent adversity.

A nurse caring for a client diagnosed with major depressive disorder reads in the client's medical record, "This client shows vegetative signs of depression." Which nursing diagnoses most clearly relate to this documentation? (Select all that apply.) a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia

a. Imbalanced nutrition: less than body requirements c. Sexual dysfunction d. Self-care deficit f. Insomnia Vegetative signs of depression are alterations in body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than diagnoses associated with feelings about self.

Which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders? a. Impaired social interaction related to difficulty maintaining relationships b. Chronic low self-esteem related to excessive negative feedback c. Deficient fluid volume related to abnormal eating habits d. Anxiety related to nightmares and repetitive activities

a. Impaired social interaction related to difficulty maintaining relationships Children diagnosed with autism spectrum disorders display profoundly disturbed social relatedness. They seem aloof and indifferent to others, often preferring inanimate objects to human interaction. Language is often delayed and deviant, further complicating relationship issues. The other nursing diagnoses might not be appropriate in all cases.

The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses most likely apply to this individual? (Select all that apply.) a. Ineffective home maintenance b. Situational low self-esteem c. Chronic low self-esteem d. Disturbed body image e. Risk for injury

a. Ineffective home maintenance c. Chronic low self-esteem e. Risk for injury Shame regarding the appearance of one's home is associated with hoarding. The behavior is usually associated with chronic low self-esteem. Hoarding results in problems of home maintenance, which may precipitate injury. The self-concept may be affected, but not body image.

A client was diagnosed with seasonal affective disorder (SAD). During which month would this client's symptoms be most acute? a. January b. April c. June d. September

a. January The days are short in January, so the client would have the least exposure to sunlight. SAD is associated with disturbances in circadian rhythm. Days are longer in spring, summer, and fall

A client diagnosed with major depressive disorder does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the client. Which communication technique will be effective? a. Make observations. b. Ask the client direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the client to reduce guilt feelings

a. Make observations. Making observations about neutral topics draws the client into the reality around him or her but places no burdensome expectations for answers on the client. Acceptance and support are shown by the nurse's presence. Direct questions may make the client feel that the encounter is an interrogation. Open-ended questions are preferable if the client is able to participate in dialogue. Platitudes are never acceptable. They minimize client feelings and can increase feelings of worthlessness

A client diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? (Select all that apply.) a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict intake of processed foods

a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the client feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted.

A client referred to the eating disorders clinic has lost 35 pounds in 3 months. For which physical manifestations of anorexia nervosa should a nurse assess? (Select all that apply.) a. Peripheral edema b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo

a. Peripheral edema c. Constipation d. Hypotension f. Lanugo Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia.

A client tells the nurse, "I'm ashamed of being bipolar. When I'm manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I'm a burden to my family." These statements support which nursing diagnoses? (Select all that apply.) a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

a. Powerlessness c. Chronic low self-esteem Chronic low self-esteem and powerlessness are interwoven in the client's statements. No data support the other diagnoses.

What is the priority outcome for a client completing the fourth alcohol detoxification program in the past year? a. Prior to discharge, the client will state, "I know I need long-term treatment." b. Prior to discharge, the client will use denial and rationalization in healthy ways. c. Prior to discharge, the client will identify constructive outlets for expression of anger. d. Prior to discharge, the client will develop a trusting relationship with one staff member.

a. Prior to discharge, the client will state, "I know I need long-term treatment." The correct response recognizes the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not give enough information to determine whether anger has been identified as a problem. A trusting relationship, while desirable, should have occurred earlier in treatment.

The family of a client diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family

a. Psychoeducational A psychoeducational group explores the causes of schizophrenia, the role of medication, the importance of medication compliance, support for the ill member, and hints for living with a person with schizophrenia. Such a group can be of immeasurable practical assistance to the family. The other types of therapy do not focus on psychoeducation.

An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident? a. Rationalization b. Compensation c. Introjection d. Regression

a. Rationalization Rationalization involves unconsciously making excuses for one's behavior, inadequacies, or feelings. Regression involves the unconscious use of a behavior from an earlier stage of emotional development. Compensation involves making up for deficits in one area by excelling in another area. Introjection is an unconscious, intense identification with another person.

A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind." Which phenomenon associated with post-traumatic stress disorder (PTSD) is the soldier describing a. Re-experiencing b. Hyperarousal c. Avoidance d. Psychosis

a. Re-experiencing Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events are often associated with PTSD. The soldier has described intrusive thoughts and visions associated with reexperiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance.

After discovering discrepancies and missing controlled substances, the nursing supervisor determines that a valued, experienced staff nurse is responsible. Which actions should the nursing supervisor take? (Select all that apply.) a. Refer the nurse to a peer assistance program. b. Confront the nurse in the presence of a witness. c. Immediately terminate the nurse's employment. d. Relieve the nurse of responsibilities for client care. e. Require the nurse to undergo immediate drug testing.

a. Refer the nurse to a peer assistance program. d. Relieve the nurse of responsibilities for client care. Registered nurses may have personal substance use problems. The nursing supervisor should provide for safe client care by relieving the nurse of responsibility for client care. For those nurses experiencing addictions, there are nonpunitive alternatives to discipline programs in the form of peer assistance. Many state boards of nursing have developed an alternative to discipline program to help impaired nurses. Terminating the nurse's employment and confronting the nurse in the presence of a witness are punitive actions. The peer assistance program will manage drug testing

A client diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The client is aloof, suspicious, and says, "Two staff members I saw talking were plotting to kill me." Based on data gathered at this point, which nursing diagnoses relate? (Select all that apply.) a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation

a. Risk for other-directed violence b. Disturbed thought processes Delusions of persecution and ideas of reference support the nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the client's feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses.

A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." What is the nurse's best intervention? a. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." b. Say to the wife, "Your husband's heart was so severely damaged that it could no longer pump." c. Say to the wife, "I will call the health care provider to discuss this matter with you." d. Hold the wife's hand in silence until the family arrives.

a. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." The nurse builds trust and shows compassion in the face of adjustment disorders. Therapeutic responses provide comfort. The nurse should show patience and tact while offering sympathy and warmth. The distracters are defensive, evasive, or placating.

When a client diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The client now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the client? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

a. Sedation and muscle stiffness Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the client might describe as making him or her feel like a "robot." The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the client.

Which features should be present in a therapeutic milieu for a client experiencing a hallucinogen overdose? a. Simple and safe b. Active and bright c. Stimulating and colorful d. Confrontational and challenging

a. Simple and safe Because the individual who has ingested a hallucinogen is probably experiencing feelings of unreality and altered sensory perceptions, the best environment is one that does not add to the stimulation. A simple, safe environment is a better choice than an environment with any of the characteristics listed in the other options. The other options would contribute to a "bad trip."

Which documentation for a client diagnosed with major depressive disorder indicates the treatment plan was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."

a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. Sleeping 6 hours, participating with a group, and anticipating an event are all positive findings that suggest effectiveness of the plan of care. All the other options show at least one negative finding.

Soon after parents announced they were divorcing, a child stopped participating in sports, sat alone at lunch, and avoided former friends. The child told the school nurse, "If my parents loved me, they would work out their problems." Which nursing diagnosis has the highest priority? a. Social isolation b. Decisional conflict c. Chronic low self-esteem d. Disturbed personal identity

a. Social isolation This child shows difficulty coping with problems associated with the family. Social isolation refers to aloneness that the patient perceives negatively, even when self-imposed. The other options are not supported by data in the scenario.

An adult diagnosed with major depressive disorder was treated with medication and cognitive-behavioral therapy. The client now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Desensitization techniques d. Use of complementary therapy

a. Social skills training Social skills training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and development of a client's support system. Use of complementary therapy refers to adjunctive therapies such as herbals, which would be less helpful than social skills training. Assertiveness would be of greater value than relaxation training because passivity was a concern. Desensitization is used in treatment of phobias.

A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information? a. Substance Abuse and Mental Health Services Administration (SAMHSA) b. Institute of Medicine (IOM)-National Research Council c. National Council of State Boards of Nursing (NCSBN) d. American Society of Addictions Medicine

a. Substance Abuse and Mental Health Services Administration (SAMHSA) The SAMHSA is the official resource for comprehensive information regarding addictions. The other resources have relevant information, but they are not as comprehensive.

A 7-year-old child was diagnosed with pica. Which assessment finding would the nurse expect associated with this diagnosis? a. The child frequently eats newspapers and magazines. b. The child refuses to eat peanut butter and jelly sandwiches. c. The child often rechews and re-swallows foods at mealtimes. d. The parents feed the child clay because of concerns about anemia

a. The child frequently eats newspapers and magazines. Pica refers to eating nonfood items after maturing past toddlerhood. Some cultures practice eating nonfood items; however, this factor is a cultural preference rather than a disorder. Refusing to eat peanut butter and jelly sandwiches is an example of a simple food preference in a child. Rumination refers to regurgitation with rechewing, re-swallowing, or spitting.

Which assessment finding would cause the nurse to consider a child to be most at risk for the development of mental illness? a. The child has been raised by a parent with recurring major depressive disorder. b. The child's best friend was absent from the child's birthday party. c. The child was not promoted to the next grade one year. d. The child moved to three new homes over a 2-year period.

a. The child has been raised by a parent with recurring major depressive disorder. Children raised by a depressed parent have an increased risk of developing an emotional disorder. Familial risk factors correlate with child psychiatric disorders, including severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster-care placement. The chronicity of the parent's depression means it has been a consistent stressor. The other factors are not as risk-enhancing.

A client became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. a. The client will verbalize realistic positive characteristics about self by (date). b. The client will agree to take an antidepressant medication regularly by (date). c. The client will initiate social interaction with another person daily by (date). d. The client will identify two personal behaviors that alienate others by (date).

a. The client will verbalize realistic positive characteristics about self by (date). Low self-esteem is reflected by making consistently negative statements about self and self- worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept.

The treatment team discusses adding a new prescription for lisdexamfetamine dimesylate to the plan of care for a client diagnosed with binge eating disorder. Which finding from the nursing assessment is most important for the nurse to share with the team? a. The client's history of poly-substance abuse b. The client's preference for homeopathic remedies c. The client's family history of autoimmune disorders d. The client's comorbid diagnosis of a learning disability

a. The client's history of poly-substance abuse Lisdexamfetamine dimesylate is designed to suppress the appetite and presents a risk for abuse. The client with a history of substance abuse is at risk to abuse this medication as well. The client's preference for homeopathic remedies is a consideration, but the history of substance abuse has a higher priority. Lisdexamfetamine dimesylate is commonly used to treat attention deficit hyperactivity disorder rather than learning disabilities. A history of autoimmune disorders in the family is irrelevant.

A nurse provides care for an adolescent client diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? a. The nurse interacts with the client in a protective fashion. b. The nurse's comments to the client are compassionate and nonjudgmental. c. The nurse teaches the client to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the client to a self-help group for individuals with eating disorders

a. The nurse interacts with the client in a protective fashion. In the effort to motivate the client and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assumption of a parental role. Protective behaviors are part of the parent's role. The helpful nurse uses a problem-solving approach and focuses on the client's feelings of shame and low self-esteem. Referring a client to a self-help group is an appropriate intervention.

When a client first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred? a. Tolerance has developed. b. Antagonistic effects are evident. c. Metabolism of the alcohol is now delayed. d. Pharmacokinetics of the alcohol have changed.

a. Tolerance has developed. Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects account for this change

Four new clients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these clients for safety. Which client diagnosis will need the most watchful supervision? a. bipolar I disorder. b. bipolar II disorder. c. dysthymic disorder. d. cyclothymic disorder.

a. bipolar I disorder. Bipolar I is a mood disorder characterized by excessive activity and energy. Psychosis (hallucinations, delusions, and dramatically disturbed thoughts) may occur during manic episodes. A client with bipolar I disorder is more unstable than a client diagnosed with bipolar II, cyclothymic disorder, or dysthymic disorder.

A child placed in a foster home after being removed from abusive parents is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. Which interventions should the nurse suggest? (Select all that apply.) a. Use a calm manner and low voice. b. Maintain simplicity in the environment. c. Avoid repetition in what is said to the child. d. Minimize opportunities for exercise and play. e. Explain and reinforce reality to avoid distortions.

a. Use a calm manner and low voice. b. Maintain simplicity in the environment. e. Explain and reinforce reality to avoid distortions. The child has moderate anxiety. A calm manner will calm the child. A simple, structured, predictable environment is desirable to decrease anxiety provoking and reduce stimuli. Calm, simple explanations that reinforce reality validate the environment. Repetition is often needed when the individual is unable to concentrate because of elevated levels of anxiety. Opportunities for play and exercise should be provided as avenues to reduce anxiety. Physical movement helps channel and lower anxiety. Play helps by allowing the child to act out concerns.

A client being treated with paroxetine 50 mg po daily reports to the clinic nurse, "I took a few extra tablets earlier today and now I feel bad." Which assessments are most critical? (Select all that apply.) a. Vital signs b. Urinary frequency c. Psychomotor retardation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

a. Vital signs d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness The client is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Serotonin syndrome may progress to a full medical emergency if not treated early. The client may have urinary retention, but frequency would not be expected.

After major reconstructive surgery, a client's wounds dehisced. Extensive wound care was required for 6 months, causing the client to miss work and social activities. Which physiological response would be expected for this client? a. Vital signs return to normal. b. Release of endogenous opioids would cease. c. Pulse and blood pressure readings are elevated. d. Psychomotor abilities of the right brain become limited

a. Vital signs return to normal. The scenario presents chronic and potentially debilitating stress. The helpless and out of control feelings produce pathophysiological changes. Unmyelinated ventral vagus responses initially result in rapid heart rate and respiration. After many hours, days, or months the body cannot sustain this state, so the dorsal vagal response dampens the sympathetic nervous system. This parasympathetic response results in the heart rate and respiration slowing down and a decrease in blood pressure. Individuals with dissociative disorders have altered communication between higher and lower brain structures due to the massive release of endogenous opioids at the time of severe threat.

What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, the symptoms that are present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.

A newly hospitalized client experiencing psychosis says, "Red chair out town board." Which term should the nurse use to document this finding? a. Word salad b. Neologism c. Anhedonia d. Echolalia

a. Word salad Word salad is a jumble of words that is meaningless to the listener and perhaps to the speaker as well, because of an extreme level of disorganization

A client diagnosed with schizophrenia begins to talks about "macnabs" hiding in the warehouse at work. The client's use of "macnabs" should be documented using what term? a. a neologism. b. concrete thinking. c. thought insertion. d. an idea of reference.

a. a neologis, A neologism is a newly coined word having special meaning to the client. "Macnabs" is not a known common word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others are implanted in one's mind. Ideas of reference are a type of delusion in which trivial events are given personal significance.

An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the client gained 8 pounds. What intervention should the nurse implement initially? a. assess lung sounds and extremities. b. suggest use of an aerobic exercise program. c. positively reinforce the client for the weight gain. d. establish a higher goal for weight gain the next week.

a. assess lung sounds and extremities. Weight gain of more than 2 to 5 pounds weekly may overwhelm the heart's capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications

The child prescribed an antipsychotic medication to manage violent behavior is one most likely diagnosed with what disorder? a. attention deficit hyperactivity disorder (ADHD). b. posttraumatic stress disorder (PTSD). c. communication disorder. d. an anxiety disorder.

a. attention deficit hyperactivity disorder (ADHD). Antipsychotic medication is useful for managing aggressive or violent behavior in some children diagnosed with ADHD. If medication were prescribed for a child with an anxiety disorder, it would be a benzodiazepine. Medications are generally not needed for children with communication disorder. Treatment of PTSD is more often associated with SSRI medications

The nurse interviewing a client with suspected post-traumatic stress disorder (PTSD) should be alert to which client findings? (Select all that apply.) a. avoids people and places that arouse painful memories. b. experiences flashbacks or re-experiences the trauma. c. experiences symptoms suggestive of a heart attack. d. feels compelled to repeat selected ritualistic behaviors. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside.

a. avoids people and places that arouse painful memories. b. experiences flashbacks or re-experiences the trauma. c. experiences symptoms suggestive of a heart attack. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside. These assessment findings are consistent with the symptoms of PTSD. Ritualistic behaviors are expected in obsessive-compulsive disorder

A client fearfully runs from chair to chair crying, "They're coming! They're coming!" The client does not follow the staff's directions or respond to verbal interventions. What is the initial nursing intervention of highest priority? a. providing for the client's safety. b. encouraging clarification of feelings. c. respecting the client's personal space. d. offering an outlet for the client's energy

a. providing for the client's safety. Safety is of highest priority because the client experiencing panic is at high risk for self-injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Offering an outlet for the client's energy can occur when the current panic level subsides. Respecting the client's personal space is a lower priority than safety. Clarification of feelings cannot take place until the level of anxiety is lowered.

A person speaking about a rival for a significant other's affection says in an emotional, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating which defense mechanism? a. reaction formation. b. repression. c. projection. d. denial.

a. reaction formation. Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise. Denial operates unconsciously to allow an anxiety-producing idea, feeling, or situation to be ignored. Projection involves unconsciously disowning an unacceptable idea, feeling, or behavior by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness.

The nurse can assist a client to prevent substance abuse relapse by (Select all that apply.) a. rehearsing techniques to handle anticipated stressful situations. b. advising the client to accept residential treatment if relapse occurs. c. assisting the client to identify life skills needed for effective coping. d. advising isolating self from significant others until sobriety is established. e. informing the client of physical changes to expect as the body adapts to functioning without substances.

a. rehearsing techniques to handle anticipated stressful situations. c. assisting the client to identify life skills needed for effective coping. e. informing the client of physical changes to expect as the body adapts to functioning without substances. Nurses can be helpful as a client assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role playing are good ways of rehearsing effective strategies for handling stressful situations and helping the client evaluate the usefulness of new strategies. The nurse can provide valuable information about physiological changes expected and ways to cope with these changes. Residential treatment is not usually necessary after relapse. Clients need the support of friends and family to establish and maintain sobriety.

A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child formed a trusting relationship with a shelter volunteer. The child says, "My three friends and I got an A on our school science project." The nurse can assess that the child demonstrating what? a. resiliency. b. a passive temperament. c. at risk for post-traumatic stress disorder (PTSD). d. intellectualization to deal with problems.

a. resiliency. Resiliency enables a child to handle the stresses of a difficult childhood. Resilient children can adapt to changes in the environment, take advantage of nurturing relationships with adults other than parents, distance themselves from emotional chaos occurring within the family, learn, and use problem-solving skills

The nurse who is counseling a client with dissociative identity disorder should understand that which assessment is of the highest priority? a. risk for self-harm. b. cognitive function. c. memory impairment. d. condition of self-esteem.

a. risk for self-harm. Assessments that relate to client safety take priority. Clients with dissociative disorders may be at risk for suicide or self-mutilation, so the nurse must be alert for indicators of risk for self- injury. The other options are important assessments but rank below safety. Treatment motivation, while an important consideration, is not necessarily a part of the nursing assessment.

The nurse receives a laboratory report indicating a client's serum level is 1 mEq/L. The client's last dose of lithium was 8 hours ago. What does this result indicate? a. within therapeutic limits. b. below therapeutic limits. c. above therapeutic limits. d. invalid because of the time lapse since the last dose.

a. within therapeutic limits. Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.6 to 1.2 mEq/L

Which comment by the parents of young children best demonstrates support of development of resilience and effective stress management? a. "Our children will be stronger if they make their own decisions." b. "We spend daily family time talking about experiences and feelings." c. "We use three different babysitters. All of them have college degrees." d. "Our parenting strategies are different from those our own parents used."

b. "We spend daily family time talking about experiences and feelings." The correct response demonstrates consistent nurturing, which is a vital component of building resilience in children. The incorrect responses are not necessarily unhealthy parenting behaviors, but they do not clearly demonstrate parental nurturing.

Which personality characteristic is a nurse most likely to assess in a client diagnosed with anorexia nervosa? a. Carefree flexibility b. Rigidity, perfectionism c. Open displays of emotion d. High spirits and optimism

b. Rigidity, perfectionism Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of clients with eating disorders. The incorrect options are rare in a client with an eating disorder. Inflexibility, controlled emotions, and pessimism are more the rule.

The spouse of a client diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide? a. "A high proportion of clients with bipolar disorders are found among creative writers." b. "A higher rate of relatives with bipolar disorder is found among clients with bipolar disorder." c. "Clients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress." d. "More individuals with bipolar disorder come from high socioeconomic and educational backgrounds."

b. "A higher rate of relatives with bipolar disorder is found among clients with bipolar disorder." Evidence of genetic transmission is supported by lifetime prevalence statistics. The incorrect options do not support the theory of genetic transmission and other factors involved in the etiology of bipolar disorder.

A Client diagnosed with alcohol use disorder asks, "How will Alcoholics Anonymous (AA) help me?" What is the nurse's best response? a. "The goal of AA is for members to learn controlled drinking with the support of a higher power." b. "An individual is supported by peers while striving for abstinence one day at a time." c. "You must make a commitment to permanently abstain from alcohol and other drugs." d. "You will be assigned a sponsor who will plan your treatment program."

b. "An individual is supported by peers while striving for abstinence one day at a time." Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support from peers are basic aspects of AA. The other options are incorrect.

Which assessment questions would be most appropriate for the nurse to ask a client with possible obsessive-compulsive disorder? (Select all that apply.) a. "Are there certain social situations that cause you to feel especially uncomfortable?" b. "Are there others in your family who must do things in a certain way to feel comfortable?" c. "Have you been a victim of a crime or seen someone badly injured or killed?" d. "Is it difficult to keep certain thoughts out of your awareness?" e. "Do you do certain things over and over again?"

b. "Are there others in your family who must do things in a certain way to feel comfortable?" d. "Is it difficult to keep certain thoughts out of your awareness?" e. "Do you do certain things over and over again?" The correct questions refer to obsessive thinking and compulsive behaviors. There is likely a genetic correlation to the disorder. The incorrect responses are more pertinent to a client with suspected posttraumatic stress disorder or with suspected social phobia.

The nurse assesses a client who reports loneliness and episodes of anxiety. Which statement by the client is mostly likely if this client also has agoraphobia? a. "I'm sure I will get over not wanting to leave home soon. It takes time." b. "Being afraid to go out seems ridiculous, but I can't go out the door." c. "My family says they like it now that I stay home most of the time." d. "When I have a good incentive to go out, I can do it."

b. "Being afraid to go out seems ridiculous, but I can't go out the door."

The nurse assesses a client who reports loneliness and episodes of anxiety. Which statement by the client is mostly likely if this client also has agoraphobia? a. "I'm sure I will get over not wanting to leave home soon. It takes time." b. "Being afraid to go out seems ridiculous, but I can't go out the door." c. "My family says they like it now that I stay home most of the time." d. "When I have a good incentive to go out, I can do it."

b. "Being afraid to go out seems ridiculous, but I can't go out the door." Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it. The symptom is ego dystonic. However, clients will state they are unable to change the behavior. Agoraphobics are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house.

A client has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today this client shouts, "They're all plotting to destroy me. Isn't that true?" what is the nurse's most therapeutic response? a. "Everyone here is trying to help you. No one wants to harm you." b. "Feeling that people want to destroy you must be very frightening." c. "That is not true. People here are trying to help you if you will let them." d. "Staff members are health care professionals who are qualified to help you."

b. "Feeling that people want to destroy you must be very frightening." Resist focusing on content; instead, focus on the feelings the client is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase client anxiety and the tenacity with which the client holds to the delusion. The other options focus on content and provide opportunity for argument.

After the sudden death of his wife, a man says, "I can't live without her ... she was my whole life." What is the nurse's most therapeutic reply? a. "Each day will get a little better." b. "Her death is a terrible loss for you." c. "It's important to recognize that she is no longer suffering." d. "Your friends will help you cope with this change in your life."

b. "Her death is a terrible loss for you." Adjustment disorders may be associated with grief. A statement that validates a bereaved person's loss is more helpful than false reassurances and clichés. It signifies understanding.

Transcranial Magnetic Stimulation (TCM) is scheduled for a client diagnosed with major depressive disorder. Which comment by the client indicates teaching about the procedure was effective? a. "They will put me to sleep during the procedure, so I won't know what is happening." b. "I might be a little dizzy or have a mild headache after each procedure." c. "I will be unable to care for my children for about 2 months." d. "I will avoid eating foods that contain tyramine."

b. "I might be a little dizzy or have a mild headache after each procedure." TCM treatments take about 30 minutes. Treatments are usually 5 days a week. Clients are awake and alert during the procedure. After the procedure, clients may experience a headache and lightheadedness. No neurological deficits or memory problems have been noted. The client will be able to care for children.

Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The soldier was diagnosed with post-traumatic stress disorder (PTSD). Which comment by the soldier requires the nurse's immediate attention? a. "It's good to be home. I missed my home, family, and friends." b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." c. "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." d. "I want to continue my education, but I'm not sure how I will fit in with other college students."

b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." The correct response indicates the soldier is thinking about death and feeling survivor's guilt. These emotions may accompany suicidal ideation, which warrants the nurse's follow-up assessment. Suicide is a high risk among military personnel diagnosed with PTSD. One distracter indicates flashbacks, common with persons with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change.

A client diagnosed with major depressive disorder tells the nurse, "Bad things that happen are always my fault." Which response by the nurse will best assist the client to reframe this overgeneralization? a. "I really doubt that one person can be blamed for all the bad things that happen." b. "Let's look at one bad thing that happened to see if another explanation exists." c. "You are being extremely hard on yourself. Try to have a positive focus." d. "Are you saying that you don't have any good things happen?"

b. "Let's look at one bad thing that happened to see if another explanation exists." By questioning a faulty assumption, the nurse can help the client look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses cast doubt but do not require the client to evaluate the statement.

A client diagnosed with bipolar disorder is in the maintenance phase of treatment. The client asks, "Do I have to keep taking this lithium even though my mood is stable now?" What is the nurse's most appropriate response? a. "You will be able to stop the medication in about 1 month." b. "Taking the medication every day helps reduce the risk of a relapse." c. "Most clients take medication for approximately 6 months after discharge." d. "It's unusual that the health care provider hasn't already stopped your medication."

b. "Taking the medication every day helps reduce the risk of a relapse." Clients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the client understand this need will promote medication adherence.

Which hallucination expressed by a client necessitates the nurse to implement safety measures? a. "I hear angels playing harps." b. "The voices say everyone is trying to kill me." c. "My dead father tells me I am a good person." d. "The voices talk only at night when I'm trying to sleep."

b. "The voices say everyone is trying to kill me." The correct response indicates the client is experiencing paranoia. Paranoia often leads to fearfulness, and the client may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia.

The unlicensed assistive personnel (UAP) says to the nurse, "That client with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her?" What is the nurse's best reply? a. "Spend as much time with her as you can and ask questions about her life." b. "Use short, simple sentences and keep the environment calm and protective." c. "Provide more information about her past to reduce the mysteries that are causing anxiety." d. "Structure her time with activities to keep her busy, stimulated, and regaining concentration."

b. "Use short, simple sentences and keep the environment calm and protective." Disruptions in ability to perform activities of daily living, confusion, and anxiety are often apparent in clients with amnesia. Offering simple directions to promote activities of daily living and reduce confusion helps increase feelings of safety and security. A calm, secure, predictable, protective environment is also helpful when a person is dealing with a great deal of uncertainty. Recollection of memories should proceed at its own pace, and the client should only gradually be given information about her past. Asking questions that require recall that the client does not possess will only add frustration. Quiet, undemanding activities should be provided as the client tolerates them and should be balanced with rest periods; the client's time should not be loaded with demanding or stimulating activities.

A client diagnosed with major depressive disorder says, "No one cares about me anymore. I'm not worth anything." Today the client is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this client? a. "You look nice this morning." b. "You're wearing a new shirt." c. "I like the shirt you are wearing." d. "You must be feeling better today."

b. "You're wearing a new shirt." Clients with depression usually see the negative side of things. The meaning of compliments may be altered to "I didn't look nice yesterday" or "They didn't like my other shirt." Neutral comments such as making an observation avoid negative interpretations. Saying, "You look nice" or "I like your shirt" gives approval (nontherapeutic techniques). Saying "You must be feeling better today" is an assumption, which is nontherapeutic

A Client asks for information about alcoholics anonymous (AA). What is the nurse's best response? " a. AA is a form of group therapy led by a psychiatrist." b. AA is a self-help group for which the goal is sobriety." c. AA is a group that learns about drinking from a group leader." d. AA is a network that advocates strong punishment for drunk drivers."

b. AA is a self-help group for which the goal is sobriety." AA is a peer support group for recovering alcoholics. Neither professional nor peer leaders are appointed. AA does not advocate punishment but supports accountability for one's actions

During a psychiatric assessment, the nurse observes a client's facial expression is without emotion. The client says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the client's affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent.

b. Affect flat; mood depressed Mood refers to a person's self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others. When there is no evidence of emotion in a person's expression, the affect is flat

A nurse reviews vital signs for a client admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/minute 0400: 126/80 mm Hg and 76 beats/minute 0600: 128/82 mm Hg and 72 beats/minute 0800: 132/88 mm Hg and 80 beats/minute 1000: 148/94 mm Hg and 96 beats/minute What is the nurse's priority action? a. Force fluids. b. Begin the detox protocol. c. Obtain a clean-catch urine sample. d. Place the Client in a vest-type restraint.

b. Begin the detox protocol. Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for detox with medical intervention to prevent a hypertensive crisis and/or seizures. No indication is present that the Client may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem

A woman is 5'7", 160 lbs. and wears a size 8 shoe. She says, "My feet are huge. I've asked three orthopedists to surgically reduce my feet." This person tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely? a. Social anxiety disorder b. Body dysmorphic disorder c. Separation anxiety disorder d. Obsessive-compulsive disorder due to a medical condition

b. Body dysmorphic disorder Body dysmorphic disorder refers to a preoccupation with an imagined defect in appearance in a normal-appearing person. The client's feet are proportional to the rest of the body. In obsessive-compulsive or related disorder due to a medical condition, the individual's symptoms of obsessions and compulsions are a direct physiological result of a medical condition. Social anxiety disorder, also called social phobia, is characterized by severe anxiety or fear provoked by exposure to a social or a performance situation that will be evaluated negatively by others. People with separation anxiety disorder exhibit developmentally inappropriate levels of concern over being away from a significant other.

A nurse prepares to lead a discussion at a community health center regarding children's health problems. The nurse wants to use current terminology when discussing these issues. Which terms are appropriate for the nurse to use? (Select all that apply.) a. Autism b. Bullying c. Mental retardation d. Autism spectrum disorder e. Intellectual development disorder

b. Bullying d. Autism spectrum disorder e. Intellectual development disorder Some dated terminology contributes to the stigma of mental illness and misconceptions about mental illness. It is important for the nurse to use current terminology.

A nurse observes a catatonic client standing immobile, facing the wall with one arm extended in a salute. The client remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Catatonia c. Depersonalization d. Thought withdrawal

b. Catatonia Catatonia is the ability to hold distorted postures for extended periods of time, as though the client were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.

A client diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the client to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data may be unreliable. b. Client involvement in decision making increases sense of control and promotes adherence to the plan of care. c. Because of increased risk of physical problems with refeeding, the client's permission is needed. d. A team approach to planning the diet ensures that physical and emotional needs will be met.

b. Client involvement in decision making increases sense of control and promotes adherence to the plan of care. A sense of control for the client is vital to the success of therapy. A diet that controls weight gain can allay client fears of too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that needs will be met. Permission for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment

A client is experiencing moderate anxiety. The nurse encourages the client to talk about feelings and concerns. What is the rationale for this intervention? a. Offering hope allays and defuses the client's anxiety. b. Concerns stated aloud become less overwhelming and help problem solving begin. c. Anxiety is reduced by focusing on and validating what is occurring in the environment. d. Encouraging clients to explore alternatives increases the sense of control and lessens anxiety.

b. Concerns stated aloud become less overwhelming and help problem solving begin. All principles listed are valid, but the only rationale directly related to the intervention of assisting the client to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming and help problem solving begin.

A client diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this client perceive the environment? a. Disorganized b. Dangerous c. Supportive d. Bizarre

b. Dangerous The client sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the client. Data are not present to support any of the other options.

A client's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the client may be hallucinating? a. Detachment and overconfidence b. Darting eyes, tilted head, mumbling to self c. Euphoric mood, hyperactivity, distractibility d. Foot tapping and repeatedly writing the same phrase

b. Darting eyes, tilted head, mumbling to self Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone.

Which nursing diagnosis would most likely apply to a client diagnosed with major depressive disorder as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

b. Disturbed sleep pattern Clients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for clients with depression. Defensive coping is more relevant for clients with mania. Fluid volume excess is less relevant for clients with mood disorders than is deficient fluid volume.

At the time of a home visit, the nurse notices that each parent and child in a family has his or her own personal online communication device. Each member of the family is in a different area of the home. Which nursing actions are appropriate? (Select all that apply.) a. Report the finding to the official child protection social services agency. b. Educate all members of the family about potential safety risks in online environments. c. Talk with the parents about parental controls on the children's communication devices. d. Encourage the family to schedule daily time together without communication devices. e. Obtain the family's network password and examine online sites family members have visited.

b. Educate all members of the family about potential safety risks in online environments. c. Talk with the parents about parental controls on the children's communication devices. d. Encourage the family to schedule daily time together without communication devices. The nurse's focus is safety, including online environments. Education and awareness-based approaches are indicated to reduce the risks of potentially harmful behavior, including risks associated with cyberbullying. Parental controls on the children's devices will support safe Internet use. Family time together will promote healthy bonding and a sense of security among members. There is no evidence of danger to the children, so a report to child protective agency is unnecessary. It would be inappropriate to seek the family's network password and an invasion of privacy to inspect sites family members have visited.

A client performs ritualistic hand washing. Which action should the nurse implement to help the client develop more effective coping? a. Allow the client to set a hand-washing schedule. b. Encourage the client to participate in social activities. c. Encourage the client to discuss hand-washing routines. d. Focus on the client's symptoms rather than on the client

b. Encourage the client to participate in social activities. Because obsessive-compulsive clients become overly involved in the rituals, promotion of involvement with other people and activities is necessary to improve coping. Daily activities prevent constant focus on anxiety and symptoms. The other interventions focus on the compulsive symptom.

A child reports to the school nurse of being verbally bullied by an aggressive classmate. What is the nurse's best first action? a. Give notice to the chief administrator at the school regarding the events. b. Encourage the victimized child to share feelings about the experience. c. Encourage the victimized child to ignore the bullying behavior. d. Discuss the events with the aggressive classmate.

b. Encourage the victimized child to share feelings about the experience. The behaviors by the bullying child create emotional pain and present the risk for physical pain. Encouraging the victimized child to share feelings about the experience provides the nurse an opportunity to further assess the situation as well as provide support to the child. The nurse should validate the child for reporting the events. Later, school authorities should be notified. School administrators are the most appropriate personnel to deal with the bullying child. The behavior should not be ignored; it will only get worse

A client diagnosed with depersonalization disorder tells the nurse, "It's starting again. I feel as though I'm going to float away." Which intervention would be most appropriate at this point? a. Notify the health care provider of this change in the client's behavior. b. Engage the client in a physical activity such as exercise. c. Isolate the client until the sensation has diminished. d. Administer a prn dose of antianxiety medication

b. Engage the client in a physical activity such as exercise. Helping the client apply a grounding technique, such as exercise, assists the client to interrupt the dissociative process. Medication can help reduce anxiety but does not directly interrupt the dissociative process. Isolation would allow the sensation to overpower the client. It is not necessary to notify the health care provider.

A nurse works with a client diagnosed with posttraumatic stress disorder (PTSD) who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? a. Trigger flashbacks intentionally in order to help the client learn to cope with them. b. Explain that the physical symptoms are related to the psychological state. c. Encourage repression of memories associated with the traumatic event. d. Support "numbing" as a temporary way to manage intolerable feelings.

b. Explain that the physical symptoms are related to the psychological state. Persons with PTSD often experience somatic symptoms or sympathetic nervous system arousal that can be confusing and distressing. Explaining that these are the body's responses to psychological trauma helps the client understand how such symptoms are part of the illness and something that will respond to treatment. This decreases powerlessness over the symptoms and helps instill a sense of hope. It also helps the client to understand how relaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of treatment for PTSD is to come to terms with the event so treatment efforts would not include repression of memories or numbing. Triggering flashbacks would increase client distress.

A soldier returned home from active duty in a combat zone and was diagnosed with post- traumatic stress disorder (PTSD). The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described? a. Illusion b. Flashback c. Nightmare d. Auditory hallucination

b. Flashback Flashbacks are dissociative reactions in which an individual feels or acts as if the traumatic event were recurring. Illusions are misinterpretations of stimuli, and although the experience is similar, it is better termed a flashback because of the diagnosis of PTSD. Auditory hallucinations have no external stimuli. Nightmares commonly accompany PTSD, but this experience was stimulated by an actual environmental sound.

The gas pedal on a person's car became stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. In the months after this experience, afterward, which assessment finding would the nurse expect? a. Weight gain b. Flashbacks c. Headache d. Diuresis

b. Flashbacks The scenario depicts a frightening, traumatic, and stressful situation. Severe dissociation or "mind flight" may occur for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks. The problems identified in the distracters may or may not occur.

A nurse leads a psychoeducational group about first-generation antipsychotic medications with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image with respect to which potential side effect of these medications? a. Constipation b. Gynecomastia c. Visual changes d. Photosensitivity

b. Gynecomastia FGAs (first-generation antipsychotic) stimulate release of prolactin, which can result in gynecomastia (enlargement of the breasts) as well as other changes in sexual function. Men may experience disturbances in body image as a result of gynecomastia. Other side effects of FGAs may be disturbing to other aspects of the client's physical health but are not likely to bother body image.

A client demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially? a. Confer with the health care provider to consider use of seclusion for this client. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and clients to discuss the behavior. d. Explain to the client that the behavior is unacceptable.

b. Hold a staff meeting to discuss consistency and limit-setting approaches. When staff members are exhausted, the client has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration.

A nurse prepares the plan of care for a client experiencing an acute manic episode. Which nursing diagnoses are most likely? (Select all that apply.) a. Imbalanced nutrition: more than body requirements b. Impaired mood regulation c. Sleep deprivation d. Chronic confusion e. Social isolation

b. Impaired mood regulation c. Sleep deprivation People with mania are hyperactive and often do not take time to eat and drink properly. Their high levels of activity consume calories, so deficits in nutrition may occur. The mood evidences euphoria and is labile. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.

A nurse wants to teach alternative coping strategies to a client experiencing severe anxiety. Which action should the nurse perform first? a. Verify the client's learning style. b. Lower the client's current anxiety. c. Create outcomes and a teaching plan. d. Assess how the client uses defense mechanisms.

b. Lower the client's current anxiety. A client experiencing severe anxiety has a markedly narrowed perceptual field and difficulty attending to events in the environment. A client experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the client's anxiety level. Use of defense mechanisms does not apply.

A client insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident? a. Visual hallucinations b. Magical thinking c. Idea of reference d. Thought insertion

b. Magical thinking Magical thinking is evident in the client's appraisal of his own abilities. There is no evidence of the distractors.

A nurse taught a client about a tyramine-restricted diet. Which menu selection would the indicate the client understood the information? a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b. Mashed potatoes, ground beef patty, corn, green beans, apple pie c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

b. Mashed potatoes, ground beef patty, corn, green beans, apple pie The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine. Fresh ground beef and apple pie are safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages/hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.

A client with an abdominal mass is scheduled for a biopsy. The client has difficulty understanding the nurse's comments and asks, "What do you mean? What are they going to do?" Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the client's level of anxiety? a. Mild b. Moderate c. Severe d. Panic

b. Moderate Moderate anxiety causes the individual to grasp less information and reduces problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem solving. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior.

At a unit meeting, the staff discusses decor for a special room for clients with acute mania. Which suggestion is appropriate? a. An extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery

b. Neutral walls with pale, simple accessories The environment for a manic client should be as simple and non-stimulating as possible. Manic clients are highly sensitive to environmental distractions and stimulation.

Which nursing intervention has the highest priority as a client diagnosed with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of refeeding. c. Communicate empathy for the client's feelings. d. Help the client balance energy expenditures with caloric intake.

b. Observe for adverse effects of refeeding. The nursing intervention of observing for adverse effects of refeeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety, as well as communicating empathy, relates to coping. Helping the client achieve balance between energy expenditure and caloric intake is an inappropriate intervention.

A client diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the client continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? a. Haloperidol b. Olanzapine c. Chlorpromazine d. Diphenhydramine

b. Olanzapine Olanzapine is a second-generation atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotics that target only positive symptoms. Diphenhydramine is an antihistamine. See relationship to audience response question.

A hospitalized Client diagnosed with alcohol use disorder believes spiders are spinning entrapping webs in the room. The client is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? a. Check the client every 15 minutes b. One-on-one supervision c. Keep the room dimly lit d. Force fluids

b. One-on-one supervision One-on-one supervision is necessary to promote physical safety until sedation reduces the Client's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid retention normally occurs when blood alcohol levels fall.

A client preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is most appropriate? a. Reassure the client that all nurses are skilled in providing postoperative care. b. Present the information again in a calm manner using simple language. c. Tell the client that staff is prepared to promote recovery. d. Encourage the client to express feelings to family.

b. Present the information again in a calm manner using simple language. Giving information in a calm, simple manner will help the client grasp the important facts. Introducing extraneous topics as described in the distracters will further scatter the client's attention.

A client experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the client with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.

b. Provide a subdued environment. All the options are reasonable interventions for a client with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping to balance activity and rest.

A nurse cares for a client experiencing an opioid overdose. Which focused assessment has the highest priority? a. Cardiovascular b. Respiratory c. Neurological d. Hepatic

b. Respiratory Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death among opioid abusers. The assessment of the other body systems is relevant but not the priority

A client fearfully runs from chair to chair crying, "They're coming! They're coming!" The client does not follow the staff's directions or respond to verbal interventions. Which nursing diagnosis has the highest priority? a. Fear b. Risk for injury c. Self-care deficit d. Disturbed thought processes

b. Risk for injury A client experiencing panic-level anxiety is at high risk for injury related to increased non-goal- directed motor activity, distorted perceptions, and disordered thoughts. Data are not present to support a nursing diagnosis of self-care deficit or disturbed thought processes. The client may be afraid, but the risk for injury has a higher priority since it involves the potential of physical danger.

A client diagnosed with major depressive disorder repeatedly tells staff, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. What is the priority nursing diagnosis? a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress

b. Risk for suicide A client diagnosed with major depressive disorder who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed.

When a hyperactive client diagnosed with acute mania is hospitalized, what is the initial nursing intervention? a. Allow the client to act out feelings. b. Set limits on client behavior as necessary. c. Provide verbal instructions to the client to remain calm. d. Restrain the client to reduce hyperactivity and aggression

b. Set limits on client behavior as necessary. This intervention provides support through the nurse's presence and provides structure as necessary while the client's control is tenuous. Acting out may lead to loss of behavioral control. The client will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy (ECT) treatment? a. Nutrition and hydration b. Supporting physiological stability c. Reducing disorientation and confusion d. Assisting the client to identify and test negative thoughts

b. Supporting physiological stability During the immediate posttreatment period, the client is recovering from general anesthesia; hence, the priority need is to establish and support physiological stability. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the client in identifying and testing negative thoughts is inappropriate in the immediate posttreatment period because the client may be confused.

A client diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. The clinic nurse notes that the client grimaces and constantly smacks both lips. The client's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette's syndrome d. Anticholinergic effects

b. Tardive dyskinesia Fluphenazine decanoate is a first-generation antipsychotic medication. Tardive dyskinesia is a condition involving the face, trunk, and limbs that occurs more frequently with first-generation antipsychotics than second or third generation. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette's syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.

A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." What is the nurse's best initial action? a. Tell the client, "Facebook is a safe website. You don't need to worry about Homeland Security." b. Tell the client, "You are in a safe place where you will be helped." c. Administer a prn dose of an antipsychotic medication. d. Tell the client, "You don't need to worry about that."

b. Tell the client, "You are in a safe place where you will be helped." The client is experiencing paranoia and delusional thinking, which leads to fear. Explaining that the client is in a safe place will help relieve the fear. It is not therapeutic to disagree or give advice. Medication will not relieve the immediate concern.

Police bring a client to the emergency department after an automobile accident. The client demonstrates poor coordination and slurred speech, but the vital signs are normal. The blood alcohol level is 300 mg/dL (0.30 g/dL). Considering the relationship between the assessment findings and blood alcohol level, which conclusion is most probable? a. The client rarely drinks alcohol. b. The client has a high tolerance to alcohol. c. The client has been treated with disulfiram. d. The client has ingested both alcohol and sedative drugs recently.

b. The client has a high tolerance to alcohol. A nontolerant drinker would have sleepiness and significant changes in vital signs with a blood alcohol level of 300 mg/dL (0.30 g/dL). The fact that the client is moving and talking shows a discrepancy between blood alcohol level and expected behavior and strongly indicates that the client's body is tolerant. If disulfiram and alcohol are ingested together, an entirely different clinical picture would result. The blood alcohol level gives no information about ingestion of other drugs.

A client demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine. What is the rationale for the addition of olanzapine to the medication regimen? a. To minimize the side effects of lithium. b. To bring hyperactivity under rapid control. c. To enhance the antimanic actions of lithium. d. To be used for long-term control of hyperactivity.

b. To bring hyperactivity under rapid control. Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium's antimanic activity nor minimize the side effects. Lithium will be used for long-term control.

In the emergency department, a client's vital signs are BP 66/40 mm Hg; pulse 140 beats/minute; respirations 8 breaths/minute and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to opioid intoxication. What is the priority outcome? a. The client will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. b. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/minute, and respirations at or above 12 breaths/minute. c. The client will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. d. Within 6 hours, the client's breath sounds will be clear bilaterally and throughout lung fields.

b. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/minute, and respirations at or above 12 breaths/minute. The correct short-term outcome is the only one that relates to the client's physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The client's respirations are slow and shallow, but there is no evidence of congestion.

A client says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." The nurse documents this report using what medical term? a. dysthymia. b. anhedonia. c. euphoria. d. anergia.

b. anhedonia. Anhedonia is a common finding in many types of depression. It refers to feelings of a loss of pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an elated mood. Anergia means "without energy."

A client undergoing alcohol rehabilitation decides to begin disulfiram therapy. Client teaching should include the need to (Select all that apply.) a. avoid aged cheeses. b. avoid alcohol-based skin products. c. read labels of all liquid medications. d. wear sunscreen and avoid bright sunlight. e. maintain an adequate dietary intake of sodium. f. avoid breathing fumes of paints, stains, and stripping compounds.

b. avoid alcohol-based skin products. c. read labels of all liquid medications. f. avoid breathing fumes of paints, stains, and stripping compounds. The Client must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne, smelling alcohol-laden fumes, and eating foods prepared with wine, brandy, or beer may also trigger reactions. The other options do not relate to hidden sources of alcohol.

What is the priority intervention for a client diagnosed with major depressive disorder and feelings of worthlessness? a. distracting the client from self-absorption. b. careful unobtrusive observation around the clock. c. allowing the client to spend long periods alone in meditation. d. opportunities to assume a leadership role in the therapeutic milieu.

b. careful unobtrusive observation around the clock. Approximately two-thirds of people with depression contemplate suicide. Clients with depressive disorder who exhibit feelings of worthlessness are at higher risk. Regular planned observations of the client diagnosed with depression may prevent a suicide attempt on the unit

A client experiencing acute mania is dancing atop a pool table in the recreation room. The client waves a cue in one hand and says, "I'll throw the pool balls if anyone comes near me." To best assure safety, what is the nurse's first intervention? a. tell the client, "You need to be secluded." b. clear the room of all other clients. c. help the client down from the table. d. assemble a show of force.

b. clear the room of all other clients The client's behavior demonstrates a clear risk of dangerousness to others. Safety is of primary importance. Once other clients are out of the room, a plan for managing this client can be implemented. Threatening the client or assembling a show of force is likely to exacerbate the tension.

Outcome identification for the treatment plan of a client experiencing grandiose thinking associated with acute mania will focus on what? a. developing an optimistic outlook. b. distorted thought self-control. c. interest in the environment. d. sleep pattern stabilization.

b. distorted thought self-control. The desired outcome is that the client will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Clients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes

This nursing diagnosis applies to a client experiencing acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. What is an appropriate outcome for this client? a. ask staff for assistance with feeding within 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at mealtime within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.

b. drink six servings of a high-calorie, high-protein drink each day. High-calorie, high-protein food supplements will provide the additional calories needed to offset the client's extreme hyperactivity. Sitting with others or asking for assistance does not mean the client ate or drank. The other indicator is unrelated to the nursing diagnosis.

An adult in the emergency department states, "Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind." When vital signs are slightly elevated what should the nurse suspect? a. a schizophrenic episode. b. hallucinogen ingestion. c. opium intoxication. d. cocaine overdose.

b. hallucinogen ingestion. The client who is high on a hallucinogen often experiences synesthesia (visions in sound), depersonalization, and concerns about going "crazy." Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. Phencyclidine (PCP) use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.

A client diagnosed with bipolar disorder is prescribed lithium. The client telephones the nurse to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" What advise will they give to the client? a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the client to the clinic immediately. c. drink a large glass of water with 1 teaspoon of salt added. d. take one dose of an over-the-counter antidiarrheal medication now.

b. have someone bring the client to the clinic immediately The symptoms described suggest lithium toxicity. The client should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the client should not drive and should be accompanied by another person. The incorrect options will not ameliorate the client's symptoms.

A nurse instructs a client taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of what? a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock.

b. hypertensive crisis. Clients taking MAO-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.

A client waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." What is the nurse's appropriate intervention? a. suggesting the client have a friend do the shopping and bring purchases to the unit. b. inviting the client to sit together and look at new fashion magazines. c. telling the client computer use is not allowed until self-control improves. d. asking whether the client has enough money to pay for the purchases.

b. inviting the client to sit together and look at new fashion magazines. Situations such as this offer an opportunity to use the client's distractibility to staff's advantage. Clients become frustrated when staff deny requests that the client sees as entirely reasonable. Distracting the client can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the client's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the client has enough money would likely precipitate an angry

A client experiences a sudden episode of severe anxiety. Of these medications in the client's medical record, which is most appropriate to give as a prn anxiolytic? a. buspirone b. lorazepam c. amitriptyline d. desipramine

b. lorazepam Lorazepam is a benzodiazepine used to treat anxiety. It may be given as a prn medication. Buspirone is long acting and is not useful as a prn drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents.

Which symptoms of withdrawal from opioids should the nurse assess for? a. dilated pupils, tachycardia, elevated blood pressure, and elation. b. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. c. mood lability, incoordination, fever, and drowsiness. d. excessive eating, constipation, and headache.

b. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal. Hyperthermia is likely to produce periods of diaphoresis.

What is an appropriate intervention for a client diagnosed with bulimia nervosa who binges, and purges is to teach the client? a. to eat a small meal after purging. b. not to skip meals or restrict food. c. to increase oral intake after 4 PM daily. d. the value of reading journal entries aloud to others.

b. not to skip meals or restrict food. One goal of health teaching is normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the client to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the client to eat a large breakfast but no lunch and increase intake after 4 PM will lead to late-day bingeing. Journal entries are private.

A newly admitted client diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The client states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior using which term? a. echolalia. b. paranoia c. a delusion of infidelity. d. an auditory hallucination.

b. paranoia Paranoia is an irrational fear, ranging from mild (being suspicious, wary, guarded) to profound (believing irrationally that another person intends to kill you).; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.

A client diagnosed with schizophrenia demonstrates little spontaneous movement and has catatonia. The client's activities of daily living are severely compromised. What will be an appropriate outcome for this client? a. demonstrates increased interest in the environment by the end of week 1. b. performs self-care activities with coaching by the end of day 3. c. gradually takes the initiative for self-care by the end of week 2. d. accepts tube feeding without objection by day 2.

b. performs self-care activities with coaching by the end of day 3. Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated to maintenance of nutrition.

A hospitalized client diagnosed with alcohol use disorder believes the window blinds are snakes trying to get in the room. The client is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe what medication intervention? a. narcotic analgesic, such as hydromorphone. b. sedative, such as lorazepam or chlordiazepoxide. c. antipsychotic, such as olanzapine or thioridazine. d. monoamine oxidase inhibitor antidepressant, such as phenelzine.

b. sedative, such as lorazepam or chlordiazepoxide. Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties. The client's highest needs related to a need for calming

A client diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The client threatens to hit another client. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"

c. "Do not hit anyone. If you are unable to control yourself, we will help you." When the client is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the client, threaten the client with seclusion as punishment, and ask a rhetorical question.

A client being treated for depression has taken sertraline daily for a year. The client calls the clinic nurse and says, "I stopped taking my antidepressant 2 days ago. Now I am having nausea, nervous feelings, and I can't sleep." The nurse will advise the client to: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider." d. "Resume taking your antidepressants for 2 more weeks and then discontinue them again."

c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider." The client has symptoms associated with abrupt withdrawal of the antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the client to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the client is experiencing.

A client diagnosed with major depressive disorder received six electroconvulsive therapy (ECT) sessions and aggressive doses of antidepressant medication. The client owns a small business and was counseled not to make major decisions for a month. What is the correct rationale for this counseling? a. Antidepressant medications alter catecholamine levels, which impairs decision- making abilities. b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c. Temporary memory impairments and confusion may occur with ECT. d. The client needs time to readjust to a pressured work schedule.

c. Temporary memory impairments and confusion may occur with ECT. Recent memory impairment and/or confusion may be present during and for a short time after ECT. An inappropriate business decision might be made because of forgotten important details. The rationales are untrue statements in the incorrect responses. The client needing time to reorient to a pressured work schedule is less relevant than the correct rationale.

A newly admitted client diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I am bad. I have got to get away from them." Select the nurse's most helpful reply. a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you. Focus on what we are talking about, not the voices. " d. "Forget the voices and ask some other clients to play cards with you."

c. "I'll stay with you. Focus on what we are talking about, not the voices. " Staying with a distraught client who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the client hears voices is not particularly relevant at this point. Asking if the client plans to "get away from the voices" is relevant for assessment purposes but is less helpful than offering to stay with the client while encouraging a focus on their discussion. Suggesting playing cards with other clients shifts responsibility for intervention from the nurse to the client and other clients

A client experiencing moderate anxiety says, "I feel undone." What would be the appropriate response by the nurse? a. "What would you like me to do to help you?" b. "Why do you suppose you are feeling anxious?" c. "I'm not sure I understand. Give me an example." d. "You must get your feelings under control before we can continue."

c. "I'm not sure I understand. Give me an example." Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarifying helps the client identify thoughts and feelings. Asking the client why he or she feels anxious is nontherapeutic; the client likely does not have an answer. The client may be unable to determine what he or she would like the nurse to do in order to help. Telling the client to get his or her feelings under control is a directive the client is probably unable to accomplish.

A new client beginning an alcohol rehabilitation program says, "I'm just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening." Which responses by the nurse will be most therapeutic? (Select all that apply.) a. "I see," and use interested silence. b. "I think you are drinking more than you report." c. "Social drinkers have one or two drinks, once or twice a week." d. "You describe drinking steadily throughout the day and evening." e. "Your comments show denial of the seriousness of your problem."

c. "Social drinkers have one or two drinks, once or twice a week." d. "You describe drinking steadily throughout the day and evening." The correct answers give information, summarize, and validate what the client reported but are not strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in the program.

A nurse educates a client about the antipsychotic medication regime. Afterward, which comment by the client indicates the teaching was effective? a. "I will need higher and higher doses of my medication as time goes on." b. "I need to store my medication in a cool dark place, such as the refrigerator." c. "Taking this medication regularly will reduce the severity of my symptoms." d. "If I run out or stop taking my medication, I will experience withdrawal symptoms."

c. "Taking this medication regularly will reduce the severity of my symptoms." Antipsychotic drugs provide symptom control and allow most clients diagnosed with schizophrenia to live and be treated in the community. Dosing is individually determined. Antipsychotics are not addictive; however, they should be discontinued gradually to minimize a discontinuation syndrome.

A cruel and abusive person often uses rationalization to explain the behavior. Which comment demonstrates use of this defense mechanism? a. "I don't know why I do mean things." b. "I have always had poor impulse control." c. "That person should not have provoked me." d. "I'm really a coward who is afraid of being hurt."

c. "That person should not have provoked me." Rationalization consists of justifying one's unacceptable behavior by developing explanations that satisfy the teller and attempt to satisfy the listener. The abuser is suggesting that the abuse is not his or her fault; it would not have occurred except for the provocation by the other person. The distracters indicate some measure of acceptance of responsibility for the behavior.

The parent of a child diagnosed with Tourette's disorder says to the nurse, "I think my child is faking the tics because they come and go." Which response by the nurse is accurate? a. "Perhaps your child was misdiagnosed." b. "Your observation indicates the medication is effective." c. "Tics often change frequency or severity. That doesn't mean they aren't real." d. "This finding is unexpected. How have you been administering your child's medication?"

c. "Tics often change frequency or severity. That doesn't mean they aren't real." Tics are sudden, rapid, involuntary, repetitive movements or vocalizations characteristic of Tourette's disorder. They often fluctuate in frequency, severity, and are reduced or absent during sleep.

A client referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the client which question? a. "Do you often feel fat?" b. "Who plans the family meals?" c. "What do you eat in a typical day?" d. "What do you think about your present weight?"

c. "What do you eat in a typical day?" Although all the questions might be appropriate to ask, only "What do you eat in a typical day?" focuses on the eating patterns. Asking if the client often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the client's thoughts on present weight explores the client's feelings about weight.

A nurse works with a child who is sad and irritable because the child's parents are divorcing. Why is establishing a therapeutic alliance with this child a priority? a. Therapeutic relationships provide an outlet for tension. b. Focusing on the strengths increases a person's self-esteem. c. Acceptance and trust convey feelings of security to the child. d. The child should express feelings rather than internalize them.

c. Acceptance and trust convey feelings of security to the child. Trust is frequently an issue because the child may question their trusting relationship with the parents. In this situation, the trust the child once had in parents has been disrupted, reducing feelings of security. The correct answer is the most global response.

A client diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? (Select all that apply.) a. Flexible mealtimes b. Unscheduled weight checks c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips f. Privileges correlated with emotional expression

c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips Priority milieu interventions support restoration of weight and normalization of eating patterns. This requires close supervision of the client's eating and prevention of exercise, purging, and other activities. There is strict adherence to menus. Observe clients during and after meals to prevent throwing away food or purging. Monitor all trips to the bathroom. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.

Which experiences are most likely to precipitate post-traumatic stress disorder (PTSD)? (Select all that apply.) a. A young adult bungee jumped from a bridge with a best friend. b. An 8-year-old child watched an R-rated movie with both parents. c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks. PTSD usually occurs after a traumatic event that is outside the range of usual experience. Examples are childhood physical abuse, torture/kidnap, military combat, sexual assault, and natural disasters, such as floods, tornados, earthquakes, tsunamis; human disasters, such as a bus or elevator accident; or crime-related events, such being taken hostage. The common element in these experiences is the individual's extraordinary helplessness or powerlessness in the face of such stressors. Bungee jumps by adolescents are part of the developmental task and might be frightening, but in an exhilarating way rather than a harmful way. A child may be disturbed by an R-rated movie, but the presence of the parents would modify the experience in a positive way.

A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, "If you had given him your undivided attention, he would still be alive." How should the nurse analyze this behavior? a. The comment suggests potential allegations of malpractice. b. In some cultures, grief is expressed solely through anger. c. Anger is an expected emotion in an adjustment disorder. d. The client had ambivalent feelings about her husband.

c. Anger is an expected emotion in an adjustment disorder. Symptoms of adjustment disorder run the gamut of all forms of distress including guilt, depression, and anger. Anger may protect the bereaved from facing the devastating reality of loss.

Over the past year, a client has cooked gourmet meals for the family but eats only tiny servings. This person wears layered loose clothing and currently weighs 95 pounds, after a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified

c. Anorexia nervosa Overly controlled eating behaviors, extreme weight loss, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The client with eating disorder not otherwise specified may be obese.

A soldier who served in a combat zone returned to the United States. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with post-traumatic stress disorder (PTSD)? a. Re-experiencing b. Hyperarousal c. Avoidance d. Psychosis

c. Avoidance Physiological reactions to reminders of the event that include persistent avoidance of stimuli associated with the trauma results in the individual's avoiding talking about the event or avoiding activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement. There is no evidence this soldier is having hyperarousal or reexperiencing war-related traumas. Psychosis is not evident.

Which dinner menu is best suited for a client with acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream

c. Broiled chicken breast on a roll, an ear of corn, and an apple These foods provide adequate nutrition, but more importantly, they are finger foods that the hyperactive client could eat while in motion. The foods in the incorrect options cannot be eaten without utensils.

A client states, "I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school." This scenario is most suggestive of which health problem? a. Acute stress disorder b. Dissociative amnesia c. Depersonalization disorder d. Disinhibited social engagement disorder

c. Depersonalization disorder Depersonalization disorder involves a persistent or recurrent experience of feeling detached from and outside oneself. Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and distress to the individual. Dissociative amnesia involves memory loss. Children with disinhibited social engagement disorder demonstrate no normal fear of strangers and are unusually willing to go off with strangers. Individuals with ASD (Acute Stress Disorder) experience three or more dissociative symptoms associated with a traumatic event, such as a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization; depersonalization or dissociative amnesia. In the scenario, the client experiences only one symptom.

A nurse assesses a client who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

c. Diaphoresis, weakness, and nausea Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this client's plan of care? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making

c. Hyperactivity; not eating and sleeping Safety and physiological needs have the highest priority. Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the client. The other behaviors are less threatening to the client's life.

A client diagnosed with depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. What information should the nurse provide to the client and family? a. Need to restrict sodium intake to 1 gram daily. b. Need to minimize exposure to bright sunlight. c. Importance of reporting increased suicidal thoughts. d. Importance of maintaining a tyramine-free diet

c. Importance of reporting increased suicidal thoughts. Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus, close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy.

A child diagnosed with attention deficit hyperactivity disorder (ADHD) shows hyperactivity, aggression, and impaired play. The health care provider prescribed amphetamine salts. The nurse should monitor for which desired behavior? a. Increased expressiveness in communication with others b. Abilities to identify anxiety and implement self-control strategies c. Improved abilities to participate in cooperative play with other children d. Tolerates social interactions for short periods without disruption or frustration

c. Improved abilities to participate in cooperative play with other children The goal is improvement in the child's hyperactivity, aggression, and play. The remaining options are more relevant for a child with intellectual development disorder or an anxiety disorder

Assessment data for a 7-year-old reveals an inability to take turns, blurting out answers to questions before a question is complete, and frequently interrupting others' conversations. How should the nurse document these behaviors? a. Disobedience b. Hyperactivity c. Impulsivity d. Anxiety

c. Impulsivity These behaviors are most directly related to impulsivity. Hyperactive behaviors are more physical in nature, such as running, pushing, and the inability to sit. Inattention is demonstrated by failure to listen. Defiance is demonstrated by willfully doing what an authority figure has said not to do.

The admission note indicates a client diagnosed with major depressive disorder has anergia and anhedonia. For which measures should the nurse plan? (Select all that apply.) a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation Anergia refers to a lack of energy. Anhedonia refers to the inability to find pleasure or meaning in life; thus, planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations

As a client admitted to the eating-disorder unit undresses, a nurse observes that the client's body is covered by fine, downy hair. The client weighs 70 pounds and is 5'4" tall. Which term should be used in the documentation of this assessment finding? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor

c. Lanugo The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in clients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered

A nurse will prepare teaching materials for the parents of a child newly diagnosed with attention deficit hyperactivity disorder (ADHD). Information will focus on which medication likely to be prescribed? a. Paroxetine b. Imipramine c. Methylphenidate d. Carbamazepine

c. Methylphenidate Central nervous system (CNS) stimulants are the drugs of choice for treating children diagnosed with ADHD. Methylphenidate and mixed amphetamine salts are most commonly used. None of the other drugs are psychostimulants used to treat ADHD.

A client diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates catatonia. Which client needs are of priority importance? a. Self-esteem b. Psychosocial c. Physiological d. Self-actualization

c. Physiological Physiological needs must be met to preserve life. A client with catatonia must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Cattonia may also precipitate a risk for falls; therefore, safety is a concern. Higher level needs are of lesser concern.

A person was online continuously for over 24 hours, posting rhymes on official government websites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficits and paranoia

c. Poor judgment and hyperactivity Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government websites) are characteristic of manic episodes. The distracters do not specifically apply to mania.

The nurse assesses a client diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Psychomotor agitation

c. Poor personal hygiene Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distractors are positive symptoms of schizophrenia. See relationship to audience response question.

Which finding constitutes a negative symptom associated with schizophrenia? a. Hostility b. Bizarre behavior c. Poverty of thought d. Auditory hallucinations

c. Poverty of thought Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question.

Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "The nurse manager had a headache the day I was interviewed." Which defense mechanism is evident? a. Introjection b. Conversion c. Projection d. Splitting

c. Projection Projection is the hallmark of blaming, scapegoating, prejudicial thinking, and stigmatizing others. Conversion involves the unconscious transformation of anxiety into a physical symptom. Introjection involves intense, unconscious identification with another person. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image.

The plan of care for a client in the manic state of bipolar disorder should include which interventions? (Select all that apply.) a. Touch the client to provide reassurance. b. Invite the client to lead a community meeting. c. Provide a structured environment for the client. d. Ensure that the client's nutritional needs are met. e. Design activities that require the client's concentration.

c. Provide a structured environment for the client. d. Ensure that the client's nutritional needs are met. People with mania are hyperactive, grandiose, and distractible. It is most important to ensure the client receives adequate nutrition. Structure will support a safe environment. Touching the client may precipitate aggressive behavior. Leading a community meeting would be appropriate when the client's behavior is less grandiose. Activities that require concentration will produce frustration.

A client diagnosed with schizophrenia has taken fluphenazine 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia

c. Pseudoparkinsonism Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson's disease. It frequently appears within the first month of treatment and is more common with first-generation antipsychotic drugs. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.

A nurse prepares for an initial interaction with a client with a long history of methamphetamine abuse. Which is the nurse's best first action? a. Perform a thorough assessment of the client. b. Verify that security services are immediately available. c. Self-assess personal attitude, values, and beliefs about this health problem. d. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.

c. Self-assess personal attitude, values, and beliefs about this health problem. The nurse should show compassion, care, and helpfulness for all clients, including those with addictive diseases. It is important to have a clear understanding of one's own perspective. Negative feelings may occur for the nurse; supervision is an important resource. The activities identified in the distracters occur after self-assessment.

A person has minor physical injuries after an auto accident. The person is unable to focus and says, "I feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and hyperventilation. What is the person's level of anxiety? a. Mild b. Moderate c. Severe d. Panic

c. Severe The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in panic will demonstrate markedly disturbed behavior and may lose touch with reality.

Major depressive disorder resulted after a client's employment was terminated. The client now says to the nurse, "I'm not worth the time you spend with me. I am the most useless person in the world." Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity

c. Situational low self-esteem The client's statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of situational low self-esteem. Insufficient information exists to lead to other diagnoses.

What is the nurse's priority focused assessment for side effects in a child taking methylphenidate for attention deficit hyperactivity disorder (ADHD)? a. Dystonia, akinesia, and extrapyramidal symptoms b. Bradycardia and hypotensive episodes c. Sleep disturbances and weight loss d. Neuroleptic malignant syndrome

c. Sleep disturbances and weight loss The most common side effects are gastrointestinal disturbances, reduced appetite, weight loss, urinary retention, dizziness, fatigue, and insomnia. Weight loss has the potential to interfere with the child's growth and development. The distracters relate to side effects of conventional antipsychotic medications.

A desired outcome for a 12-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care? a. Reality therapy b. Simple restitution c. Social skills group d. Insight-oriented group therapy

c. Social skills group Social skills training teaches the child to recognize the impact of his or her behavior on others. It uses instruction, role playing, and positive reinforcement to enhance social outcomes. The other therapies would have lesser or no impact on peer relationships.

A person runs from a crowded nightclub after a pyrotechnics show causes the building to catch fire. Which division of the autonomic nervous system will be stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system

c. Sympathetic nervous system The autonomic nervous system is comprised of the sympathetic (fight or flight response) and parasympathetic nervous system (relaxation response). In times of stress, the sympathetic nervous system is stimulated. A person would experience stress associated with the experience of being in danger. The peripheral nervous system responds to messages from the sympathetic nervous system. The limbic system processes emotional responses but is not specifically part of the autonomic nervous system.

A client experiencing panic suddenly began running and shouting, "I'm going to explode!" What is the nurse's best action? a. Ask, "I'm not sure what you mean. Give me an example." b. Capture the client in a basket-hold to increase feelings of control. c. Tell the client, "Stop running and take a deep breath. I will help you." d. Assemble several staff members and say, "We will take you to seclusion to help you regain control."

c. Tell the client, "Stop running and take a deep breath. I will help you." Safety needs of the client and other clients are a priority. Comments to the client should be simple, neutral, and give direction to help the client regain control. Running after the client will increase the client's anxiety. More than one staff member may be needed to provide physical limits but using seclusion or physically restraining the client prematurely is unjustified. Asking the client to give an example would be futile; a client in panic processes information poorly.

A client admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The client is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/minute. The client shouts, "Bugs are crawling on my bed. I've got to get out of here." What is the most accurate assessment of this situation? a. The client is attempting to obtain attention by manipulating staff. b. The client may have sustained a head injury before admission. c. The client has symptoms of alcohol withdrawal delirium. d. The client is having an acute psychosis.

c. The client has symptoms of alcohol withdrawal delirium. Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

A client diagnosed with schizophrenia begins a new prescription for ziprasidone. The client is 5'6'' and currently weighs 204 lbs. The client has dry flaky skin, headaches about twice a month, and a family history of colon cancer. Which intervention has the highest priority for the nurse to include in the client's plan of care? a. Skin care techniques b. Scheduling a colonoscopy c. Weight management strategies d. Teaching to limit caffeine intake

c. Weight management strategies Ziprasidone is a second-generation antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with second-generation antipsychotic medications. The client is overweight now, so weight management will be especially important. The other interventions may occur in time, but do not have the priority of weight management.

When alprazolam is prescribed for a client who experiences acute anxiety, health teaching should include which instruction? a. report drowsiness. b. eat a tyramine-free diet. c. avoid alcoholic beverages. d. adjust dose and frequency based on anxiety level

c. avoid alcoholic beverages. Drinking alcohol or taking other anxiolytics along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected effect and needs to be reported only if it is excessive. Clients should be taught not to deviate from the prescribed dose and schedule for administration.

When counseling clients diagnosed with major depressive disorder, what therapy would an advanced practice nurse address the client's negative thought patterns? a. psychoanalytic b. desensitization c. cognitive-behavioral d. alternative and complementary

c. cognitive-behavioral Cognitive-behavioral therapy attempts to alter the client's dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The client is also taught the connection between thoughts and resultant feelings. Research shows that cognitive-behavioral therapy involves the formation of new connections between nerve cells in the brain and that it is at least as effective as medication. Evidence is not present to support superior outcomes for the other psychotherapeutic modalities mentioned.

The treatment team discusses the plan of care for a client diagnosed with schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the team should consider what intervention? a. provide long-term care for the client in a residential facility. b. withdraw the client from cannabis, then treat the schizophrenia. c. consider each diagnosis primary and provide simultaneous treatment. d. first treat the schizophrenia, then establish goals for substance abuse treatment.

c. consider each diagnosis primary and provide simultaneous treatment. Both diagnoses should be considered primary and receive simultaneous treatment. Comorbid disorders require longer treatment and progress is slower, but treatment may occur in the community

A soldier returns to the United States from active duty in a combat zone. The soldier is diagnosed with post-traumatic stress disorder (PTSD). The nurse's highest priority is to screen this soldier for a. bipolar disorder. b. schizophrenia. c. depression. d. dementia.

c. depression. Comorbidities for adults with PTSD include depression, anxiety disorders, sleep disorders, and dissociative disorders. Incidence of the disorders identified in the distracters is similar to the general population.

A client diagnosed with major depressive disorder began taking escitalopram 5 days ago. The client now says, "This medicine isn't working." What is the nurse's best intervention? a. discuss with the health care provider the need to increase the dose. b. reassure the client that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the client for symptoms of improvement

c. explain the time lag before antidepressants relieve symptoms. Escitalopram is an SSRI antidepressant. One to three weeks of treatment is usually necessary before symptom relief occurs. This information is important to share with clients.

Which behavior indicates that the treatment plan for a child diagnosed with an autism spectrum disorder was effective? a. plays with one toy for 30 minutes. b. repeats words spoken by a parent. c. holds the parent's hand while walking. d. spins around and claps hands while walking.

c. holds the parent's hand while walking. Holding the hand of another person suggests relatedness. Usually, a child diagnosed with an autism spectrum disorder would resist holding someone's hand and stand or walk alone, perhaps flapping arms or moving in a stereotyped pattern. The incorrect options reflect behaviors that are consistent with autism spectrum disorders.

A nurse provides health teaching for a client diagnosed with bulimia nervosa. What is the priority information the nurse should provide? a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. how to recognize hypokalemia. d. self-esteem maintenance.

c. how to recognize hypokalemia. Hypokalemia results from potassium loss associated with vomiting. Physiological integrity can be maintained if the client can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the client purges. Daily weight gain may not be desirable for a client with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the dangers associated with hypokalemia

A nurse prepares the plan of care for a 15-year-old diagnosed with moderate intellectual developmental disorder. What are the highest outcomes that are realistic for this patient? Within 5 years, the patient will (Select all that apply.) a. graduate from high school. b. live independently in an apartment. c. independently perform own personal hygiene. d. obtain employment in a local sheltered workshop. e. correctly use public buses to travel in the community.

c. independently perform own personal hygiene. d. obtain employment in a local sheltered workshop. e. correctly use public buses to travel in the community. Individuals with moderate intellectual developmental disorder progress academically to about the second grade. These people can learn to travel in familiar areas and perform unskilled or semiskilled work. With supervision, the person can function in the community, but independent living is not likely.

Consider these three anticonvulsant medications: divalproex, carbamazepine, and gabapentin. Which medication also belongs to this classification? a. clonazepam b. risperidone c. lamotrigine d. aripiprazole

c. lamotrigine The three drugs in the stem of the question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs.

A kindergartener is disruptive in class. This child is unable to sit for expected lengths of time, inattentive to the teacher, screams while the teacher is talking, and is aggressive toward other children. The nurse plans interventions designed to achieve what? a. integration of self-concept. b. inpatient treatment for the child. c. loneliness and increase self-esteem. d. language and communication skills.

c. loneliness and increase self-esteem. Because of their disruptive behaviors, children diagnosed with attention deficit hyperactivity disorder (ADHD) often receive negative feedback from parents, teachers, and peers, leading to self-esteem disturbance. These behaviors also cause peers to avoid the child with ADHD, leaving the child with ADHD vulnerable to loneliness. The child does not need inpatient treatment at this time. The incorrect options might or might not be relevant.

A client diagnosed with obsessive-compulsive disorder has this nursing diagnosis: Anxiety related to___________________ as evidenced by inability to control compulsive cleaning. Which phrase correctly completes the etiological portion of the diagnosis? a. feelings of responsibility for the health of family members b. approval-seeking behavior from friends and family c. persistent thoughts about bacteria, germs, and dirt d. needs to avoid interactions with others

c. persistent thoughts about bacteria, germs, and dirt Many compulsive rituals accompany obsessive thoughts. The client uses these rituals for anxiety relief. Unfortunately, the anxiety relief is short lived, and the client must frequently repeat the ritual. The other options are unrelated to the dynamics of compulsive behavior.

When group therapy is prescribed as a treatment modality, the nurse would suggest placement of a 9-year-old in a group that uses what strategy? a. guided imagery. b. talk focused on a specific issue. c. play and talk about a play activity. d. group discussion about selected topics.

c. play and talk about a play activity. Group therapy for young children takes the form of play. For elementary school children, therapy combines play and talk about the activity. For adolescents, group therapy involves more talking.

Why does the nurse conducting group therapy on the eating-disorder unit schedule the sessions immediately after meals? a. maintains clients' concentration and attention. b. shifts the clients' focus from food to psychotherapy. c. promotes processing of anxiety associated with eating. d. focuses on weight control mechanisms and food preparation.

c. promotes processing of anxiety associated with eating. Eating produces high anxiety for clients with eating disorders. Anxiety levels must be lowered if the client is to be successful in attaining therapeutic goals. Shifting the clients' focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining clients' concentration and attention is important, but not the primary purpose of the schedule.

A client experiencing acute mania undresses in the group room and dances. How should the nurse intervene initially? a. quietly asking the client, "Why don't you put your clothes on?" b. firmly telling the client, "Stop dancing and put on your clothing." c. putting a blanket around the client and walking with the client to a quiet room. d. letting the client stay in the group room and moving the other clients to a different area.

c. putting a blanket around the client and walking with the client to a quiet room. Clients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the client from public exposure by matter-of-factly covering the client and removing him or her from the area with a sufficient number of staff to avoid argument and provide control is an effective approach.

A client tells a nurse, "My best friend is a perfect person. She is kind, considerate, good-looking, and successful with every task. I could have been like her if I had the opportunities, luck, and money she's had." This client is demonstrating a. denial. b. projection. c. rationalization. d. compensation.

c. rationalization. Rationalization consists of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener. Denial is an unconscious process that would call for the nurse to ignore the existence of the situation. Projection operates unconsciously and would result in blaming behavior. Compensation would result in the nurse unconsciously attempting to make up for a perceived weakness by emphasizing a strong point.

When a 5-year-old is disruptive, the nurse says, "You must take a time-out." The expectation is that the child will do what? a. go to a quiet room until called for the next activity. b. slowly count to 20 before returning to the group activity. c. sit on the edge of the activity until able to regain self-control. d. sit quietly on the lap of a staff member until able to apologize for the behavior.

c. sit on the edge of the activity until able to regain self-control. Time-out is designed so that staff can be consistent in their interventions. Time-out may require going to a designated room or sitting on the periphery of an activity until the child gains self-control and reviews the episode with a staff member. Time-out may not require going to a designated room and does not involve special attention such as holding. Counting to 10 or 20 is not sufficient.

A client has smoked two packs of cigarettes daily for many years. When the client tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario should be described using which term? a. cross-tolerance. b. substance abuse. c. substance addiction. d. substance intoxication

c. substance addiction. Nicotine meets the criteria for a "substance," the criterion for addiction is present, and withdrawal symptoms are noted with abstinence or reduction of dose. The scenario does not meet criteria for substance abuse, intoxication, or cross-tolerance

A client diagnosed with major depressive disorder began taking a tricyclic antidepressant 1 week ago. Today the client says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse will implement which intervention? a. limit the client's activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the client strategies to manage postural hypotension. d. update the client's mental status examination.

c. teach the client strategies to manage postural hypotension. Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the client to stay well hydrated and rise slowly. Knowing this information may convince the client to continue the medication. Activity is an important aspect of the client's treatment plan and should not be limited to activities that can be done in a sitting position. Withholding the drug, forcing oral fluids, and notifying the health care provider are unnecessary actions. Independent nursing action is called for. Updating a mental status examination is unnecessary.

A nurse finds a client diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. I am afraid you will lose more weight." c. "Let's discuss the relationship between exercise, weight loss, and the effects on your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight." A matter-of-fact statement that the nurse's perceptions are different will help to avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Clients must be held accountable for required behaviors.

A psychiatric clinical nurse specialist uses cognitive-behavioral therapy for a client diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. "What are your feelings about not eating foods that you prepare?" b. "You seem to feel much better about yourself when you eat something." c. "It must be difficult to talk about private matters to someone you just met." d. "Being thin doesn't seem to solve your problems. You are thin now but still unhappy."

d. "Being thin doesn't seem to solve your problems. You are thin now but still unhappy." The correct response is the only strategy that questions the client's distorted thinking.

A nurse assesses a client with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask? a. "Have you been a victim of a crime or seen someone badly injured or killed?" b. "Do you feel especially uncomfortable in social situations involving people?" c. "Do you repeatedly do certain things over and over again?" d. "Do you find it difficult to control your worrying?"

d. "Do you find it difficult to control your worrying?" Clients with generalized anxiety disorder frequently engage in excessive worrying. They are less likely to engage in ritualistic behavior, fear social situations, or have been involved in a highly traumatic event.

A 4-year-old cries for 5 minutes when the parents leave the child at preschool. The parents ask the nurse, "What should we do?" What is the nurse's best response? a. "Ask the teacher to let the child call you at play time." b. "Withdraw the child from preschool until maturity increases." c. "Remain with your child for the first hour of preschool time." d. "Give your child a kiss before you leave the preschool program."

d. "Give your child a kiss before you leave the preschool program." The child demonstrates age-appropriate behavior for a 4-year-old. The nurse should reassure the parents. The distracters are over-reactions.

A client diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" What is the nurse's most therapeutic response? a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts and then tell me again." d. "I am having difficulty understanding what you are saying."

d. "I am having difficulty understanding what you are saying." When a client's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the client that he or she is having difficulty understanding what the client is saying. If a theme is discernible, ask the client to talk about the theme. The incorrect options tend to place blame for the poor communication with the client. The correct response places the difficulty with the nurse rather than being accusatory.

A client became severely depressed when the last of the family's six children moved out of the home 4 months ago. The client repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? a. "Things will look brighter soon. Everyone feels down once in a while." b. "Our staff members care about you and want to try to help you get better." c. "It is difficult for others to care about you when you repeatedly say the same negative things." d. "I'd to sit with you for 10 minutes now and 10 minutes after lunch because I value spending time with you."

d. "I'd to sit with you for 10 minutes now and 10 minutes after lunch because I value spending time with you." Spending time with the client at intervals throughout the day shows acceptance by the nurse and will help the client establish a relationship with the nurse. The therapeutic technique is "offering self." Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters trust building. The incorrect responses would be difficult for a person with profound depression to believe, provide false reassurance, and are counterproductive. The client is unable to say positive things at this point.

Family members of an individual undergoing a residential alcohol rehabilitation program ask, "How can we help?" What is the nurse's best response? a. "Alcoholism is a lifelong disease. Relapses are expected." b. "Use search and destroy tactics to keep the home alcohol free." c. "It's important that you visit your family member on a regular basis." d. "Make your loved one responsible for the consequences of behavior."

d. "Make your loved one responsible for the consequences of behavior." Often, the addicted individual has been enabled when others picked up the pieces for him or her. The individual never faced the consequences of his or her own behaviors, all of which relate to taking responsibility. Learning to face those consequences is part of the recovery process. The other options are codependent behaviors or are of no help.

A soldier returned home last year after deployment to a war zone. The soldier's spouse complains, "We were going to start a family, but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." Select the nurse's best response. a. "Posttraumatic stress disorder (PTSD) often changes a person's sexual functioning." b. "I encourage you to continue to participate in social activities where children are present." c. "Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior." d. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support."

d. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support." PTSD precipitates changes that can lead to divorce. It is important to provide support to both the veteran and spouse. Confrontation will not be effective. While it is important to provide information, on-going support will be more effective.

A client diagnosed with alcohol use disorder says, "Drinking helps me cope with being a single parent." Which therapeutic response by the nurse would help the client conceptualize the drinking objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank."

d. "Tell me what happened the last time you drank." The correct response will help the client see alcohol as a cause of the problems, not a solution, and begin to take responsibility. This approach can help the client become receptive to the possibility of change. The other responses directly confront and attack defenses against anxiety that the client still needs. They reflect the nurse's frustration with the client.

A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of schizoaffective disorder, cries spontaneously when talking about his death. What is the nurse's most therapeutic response? a. "Are you taking your medications the way they are prescribed?" b. "This loss is harder to accept because of your mental illness. Do you think you should be hospitalized?" c. "I'm worried about how much you are crying. Your grief over your husband's death has gone on too long." d. "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings."

d. "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings." The client is expressing feelings related to the loss, and this is an expected and healthy behavior. This client is at risk for a maladaptive response because of the history of a serious mental illness, but the nurse's priority intervention is to form a therapeutic alliance and support the client's expression of feelings. Crying at 2 weeks after his death is expected and normal.

A client diagnosed with schizophrenia anxiously tells the nurse, "The voice is telling me to do things." What is the nurse's priority assessment question? a. "How long has the voice been directing your behavior?" b. "Does what the voice tell you to do frighten you?" c. "Do you recognize the voice speaking to you?' d. "What is the voice telling you to do?"

d. "What is the voice telling you to do?" Learning what a command hallucination is telling the client to do is important because the command often places the client or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command

A nurse sits with a client diagnosed with schizophrenia. The client starts to laugh uncontrollably, although the nurse has not said anything funny. What is the nurse's most therapeutic response? a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening."

d. "You're laughing. Tell me what's happening." The client is likely laughing in response to inner stimuli, such as hallucinations or fantasy. Focus on the hallucinatory clue (the client's laughter) and then elicit the client's observation. The incorrect options are less useful in eliciting a response: no joke may be involved, "why" questions are difficult to answer, and the client is probably not focusing on what the nurse said in the first place.

Which child demonstrates behaviors indicative of a neurodevelopmental disorder? a. A 4-year-old who stuttered for 3 weeks after the birth of a sibling b. A 9-month-old who does not eat vegetables and likes to be rocked c. A 3-month-old who cries after feeding until burped and sucks a thumb d. A 3-year-old who is mute, passive toward adults, and twirls while walking

d. A 3-year-old who is mute, passive toward adults, and twirls while walking Symptoms consistent with autistic spectrum disorders (ASD) are evident in the correct answer. ASD is one type of neurodevelopmental disorder. The behaviors of the other children are within normal ranges.

Which goal for treatment of alcohol use disorder should the nurse address first? a. Learn about addiction and recovery. b. Develop alternate coping strategies. c. Develop a peer support system. d. Achieve physiological stability

d. Achieve physiological stability The individual must have completed withdrawal and achieved physiological stability before he or she is able to address any of the other treatment goals

A health care provider considers which antipsychotic medication to prescribe for a client diagnosed with schizophrenia who has auditory hallucinations and poor social function. The client is also overweight and hypertensive. Which drug should the nurse advocate? a. Clozapine b. Ziprasidone c. Olanzapine d. Aripiprazole

d. Aripiprazole Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a client with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a client with cardiac disease. Olanzapine fosters weight gain.

A client diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

d. Associative looseness Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one's thoughts.

The nursing care plan for a client diagnosed with anorexia nervosa includes the intervention "monitor for complications of refeeding." Which system should a nurse closely monitor for dysfunction? a. Renal b. Endocrine c. Integumentary d. Cardiovascular

d. Cardiovascular Refeeding resulting in too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment is a necessity to ensure the client's physiological integrity. The other body systems are not initially involved in the refeeding syndrome.

Disturbed body image is a nursing diagnosis established for a client diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat congruence with height, frame, age, and sex b. Calorie intake is within required parameters of treatment plan c. Weight reaches established normal range for the client d. Client expresses satisfaction with body appearance

d. Client expresses satisfaction with body appearance Body image disturbances are considered improved or resolved when the client is consistently satisfied with his or her own appearance and body function. This is a subjective consideration. The other indicators are more objective but less related to the nursing diagnosis.

A client with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the client's behavior? a. Educate the client about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the client's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The client may not be swallowing medications.

d. Consider the need to check the lithium level. The client may not be swallowing medications. The client continues to exhibit manic symptoms. Nonadherence to the medication regime is a common problem for clients diagnosed with bipolar disorder. The lithium level should be approaching a therapeutic range after 7 days but may be low from "cheeking" (not swallowing) the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Monitoring the client does not address the problem.

A client undergoing diagnostic tests says, "Nothing is wrong with me except a stubborn chest cold." The spouse reports the client smokes, coughs daily, lost 15 pounds, and is easily fatigued. Which defense mechanism is the client using? a. Displacement b. Regression c. Projection d. Denial

d. Denial Denial is an unconscious blocking of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of psychosexual development. Displacement shifts feelings to a more neutral person or object. Projection attributes one's own unacceptable thoughts or feelings to another.

Which assessment findings are likely for an individual who recently injected heroin? a. Anxiety, restlessness, paranoid delusions b. Muscle aching, dilated pupils, tachycardia c. Heightened sexuality, insomnia, euphoria d. Drowsiness, constricted pupils, slurred speech

d. Drowsiness, constricted pupils, slurred speech Heroin, an opiate, is a central nervous system (CNS) depressant. Blood pressure, pulse, and respirations will be decreased, and attention will be impaired. The distracters describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use.

A soldier returned 3 months ago from a combat zone and was diagnosed with post-traumatic stress disorder (PTSD). Which social event would be most disturbing for this soldier? a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. A family outing to the seashore d. Fireworks display on July 4th

d. Fireworks display on July 4th The exploding noises associated with fireworks are likely to provoke exaggerated responses for this soldier. The distracters are not associated with offensive sounds.

A client newly diagnosed with bipolar disorder is prescribed lithium. Which information from the client's medical history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure

d. Heart failure The client with heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity. None of the other options would present such a challenge.

Which nursing diagnosis is more appropriate for a client diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound client diagnosed with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements

d. Imbalanced nutrition: less than body requirements The client with bulimia nervosa usually maintains a close to normal weight, whereas the client with anorexia nervosa may approach starvation. The incorrect options may be appropriate for clients with either anorexia nervosa or bulimia nervosa.

A client was diagnosed with anorexia nervosa. The history shows the client virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies? a. Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

d. Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia The client's history and lab result support the nursing diagnosis Imbalanced nutrition: less than body requirements. Data are not present that the client uses laxatives, induces vomiting, or exercises excessively. The client has hypokalemia rather than hyperkalemia.

A client being admitted to the eating-disorder unit has a yellow cast to the skin and fine, downy hair over the trunk. The client weighs 70 pounds; height is 5'4". The client says, "I won't eat until I look thin." What is the priority initial nursing diagnosis? a. Anxiety related to fear of weight gain b. Disturbed body image related to weight loss c. Ineffective coping related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements related to self-starvation

d. Imbalanced nutrition: less than body requirements related to self-starvation The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the client's self-starvation is the priority.

A nurse leads a psychoeducational group about problem solving with six adults diagnosed with schizophrenia. Which teaching strategy is likely to be most effective? a. Suggest analogies that might apply to a common daily problem. b. Assign each participant a problem to solve independently and present to the group. c. Ask each client to read aloud a short segment from a book about problem solving. d. Invite participants to come up with solution to getting incorrect change for a purchase.

d. Invite participants to come up with solution to getting incorrect change for a purchase. Concrete thinking, an impaired ability to think abstractly resulting in interpreting or perceiving things in a literal manner, is evident in many clients diagnosed with schizophrenia. People who think concretely benefit from concrete situations during education. Finding a solution in order to get incorrect change for a purchase is an example of a concrete situation. Analogies require abstract thinking and insight. Independently solving a problem and presenting it to the group may be intimidating. All participants may or may not be literate.

A client diagnosed with major depressive disorder refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this client? a. Tomato juice b. Orange juice c. Hot tea d. Milk

d. Milk Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.

Which medication to maintain abstinence would most likely be prescribed for clients diagnosed with an addiction to either alcohol or opioids? a. Bromocriptine b. Methadone c. Disulfiram d. Naltrexone

d. Naltrexone Naltrexone is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving. None of the other options are associated with such a response.

A client receiving risperidone reports severe muscle stiffness at 1030. By 1200, the client has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The client is diaphoretic. What is the nurse's best analysis and action? a. Agranulocytosis; institute reverse isolation. b. Tardive dyskinesia; withhold the next dose of medication. c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet. d. Neuroleptic malignant syndrome; notify health care provider stat.

d. Neuroleptic malignant syndrome; notify health care provider stat. Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options

A client diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia

d. Paranoia The client's unrealistic fear of harm indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information.

For a client experiencing panic, which nursing intervention should be implemented first? a. Teach relaxation techniques. b. Administer an anxiolytic medication. c. Prepare to implement physical controls. d. Provide calm, brief, directive communication.

d. Provide calm, brief, directive communication. Calm, brief, directive verbal interaction can help the client gain control of overwhelming feelings and impulses related to anxiety. Clients experiencing panic-level anxiety are unable to focus on reality; thus, learning relaxation techniques is virtually impossible. Administering anxiolytic medication should be considered if providing calm, brief, directive communication is ineffective. Although the client is disorganized, violence may not be imminent, ruling out the intervention of preparing for physical control until other less-restrictive measures are proven ineffective.

A client diagnosed with an antisocial personality disorder was treated several times for substance abuse, but each time the client relapsed. Which treatment approach is most appropriate? a. 1-week detoxification program b. Long-term outpatient therapy c. 12-step self-help program d. Residential program

d. Residential program Residential programs and therapeutic communities help clients change lifestyles, abstain from drugs, eliminate criminal behaviors, develop employment skills, become self-reliant, and practice honesty. Residential programs are more effective for clients with antisocial tendencies than outpatient programs.

A client admitted yesterday for injuries sustained while intoxicated believes insects are crawling on the bed. The client is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury

d. Risk for injury The client's clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurse's priority. The other diagnoses may apply but are not the priorities of care since none are related to the client's physical needs.

Which assessment finding for a client diagnosed with an eating disorder meets criteria for hospitalization? a. Urine output 40 mL/hour b. Pulse rate 58 beats/min c. Serum potassium 3.4 mEq/L d. Systolic blood pressure 62 mm Hg

d. Systolic blood pressure 62 mm Hg Systolic blood pressure less than 90 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 mL/hour. A potassium level of 3.4 mEq/L is within the normal range.

When a 5-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) bounces out of a chair and runs over and slaps another child, what is the nurse's best action? a. Instruct the parents to take the aggressive child home. b. Direct the aggressive child to stop immediately. c. Call for emergency assistance from other staff. d. Take the aggressive child to another room.

d. Take the aggressive child to another room. The nurse should manage the milieu with structure and limit setting. Removing the aggressive child to another room is an appropriate consequence for the aggressiveness. Directing the child to stop will not be effective. This is not an emergency. Intervention is needed rather than sending the child home.

A person who has been unable to leave home for more than a week because of severe anxiety says, "I know it does not make sense, but I just can't bring myself to leave my apartment alone." Which nursing intervention is appropriate? a. Help the person use online video calls to provide interaction with others. b. Advise the person to accept the situation and use a companion. c. Ask the person to explain why the fear is so disabling. d. Teach the person to use positive self-talk techniques.

d. Teach the person to use positive self-talk techniques. Positive self-talk, a form of cognitive restructuring, replaces negative thoughts such as "I can't leave my apartment" with positive thoughts such as "I can control my anxiety." This technique helps the client gain mastery over the symptoms. The other options reinforce the sick role.

A client diagnosed with major depressive disorder is receiving imipramine 200 mg at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth b. Blurred vision c. Nasal congestion d. Urinary retention

d. Urinary retention All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.

A client is thin, tense, jittery, and has dilated pupils. The client says, "My heart is pounding in my chest. I need help." The client allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The client refuses further examination. Abuse of which substance is most likely? a. phencyclidine (PCP) b. Heroin c. Barbiturates d. amphetamines

d. amphetamines The physical symptoms are consistent with central nervous system (CNS) stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behavior. Barbiturates and heroin would result in symptoms of CNS depression.

A client diagnosed with acute mania has disrobed in the hall three times in 2 hours. What intervention should the nurse implement? a. direct the client to wear clothes at all times. b. ask if the client finds clothes bothersome. c. tell the client that others feel embarrassed. d. arrange for one-on-one supervision.

d. arrange for one-on-one supervision. A client who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure. Directing the client to wear clothes at all times has not proven successful, considering the behavior has continued. Asking if the client is bothered by clothing serves no purpose. Telling the client that others are embarrassed will not make a difference to the client whose grasp of social behaviors is impaired by the illness.

The parent of a 6-year-old says, "My child is in constant motion and talks all the time. My child isn't interested in toys but is out of bed every morning before me." The child's behavior is most consistent with diagnostic criteria for which disorder? a. communication disorder. b. stereotypic movement disorder. c. intellectual development disorder. d. attention deficit hyperactivity disorder (ADHD).

d. attention deficit hyperactivity disorder (ADHD). Excessive motion, distractibility, and excessive talkativeness are seen in ADHD. The behaviors presented in the scenario do not suggest intellectual development, stereotypic, or communication disorder.

A client diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin b. clonidine c. risperidone d. carbamazepine

d. carbamazepine Some clients diagnosed with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Carbamazepine seems to work better in clients with rapid cycling and in severely paranoid, angry manic clients. Phenytoin is also an anticonvulsant but not used for mood stabilization. Risperidone is not an anticonvulsant.

What is the correct etiology to complete this nursing diagnosis for a client diagnosed with dissociative identity disorder? a. obsessive fears of harming self or others. b. poor impulse control and lack of self- confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.

d. cognitive distortions associated with unresolved childhood abuse issues. Nearly all clients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant.

A client checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and client explore the likelihood of an actual fire. The client states this event is not likely. This counseling demonstrates what appropriate principle of therapy? a. flooding. b. desensitization. c. relaxation technique. d. cognitive restructuring.

d. cognitive restructuring. Cognitive restructuring involves the client in testing automatic thoughts and drawing new conclusions. Desensitization involves graduated exposure to a feared object. Relaxation training teaches the client to produce the opposite of the stress response. Flooding exposes the client to a large amount of an undesirable stimulus in an effort to extinguish the anxiety response

A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of what defense mechanism? a. repression. b. devaluation. c. identification. d. compensation

d. compensation Compensation is an unconscious process that allows us to make up for deficits in one area by excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for imitation of mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or others.

A nurse provided medication education for a client diagnosed with major depressive disorder who began a new prescription for phenelzine. Which behavior indicates effective learning? The client a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications

d. confers with a pharmacist when selecting over-the-counter medications. Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the client takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure

A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is most associated with the child's disorder? a. has occasional toileting accidents. b. interrupts or intrudes on others. c. cries when separated from a parent. d. continuously rocks in place for 30 minutes.

d. continuously rocks in place for 30 minutes. Autism spectrum disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Body rocking for extended periods suggests autism spectrum disorder. Occasional toileting accidents and crying when separated from a parents are expected findings for a 3-year-old. Interrupting or intruding on others are assessment findings associated with ADHD.

Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? a. visiting their teenager's grave daily. b. returning immediately to employment. c. discussing the accident within the family only. d. creating a scholarship fund at their child's high school

d. creating a scholarship fund at their child's high school Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest risk situations for maladaptive grieving. The parents who create a scholarship fund are openly expressing their feelings and memorializing their child. The other parents in this question are isolating themselves and/or denying their feelings. Visiting the grave daily shows active continued mourning but is not as strongly indicative of resilience as the correct response.

The nurse is developing a plan for psychoeducational sessions for a small group of adults diagnosed with schizophrenia. Which goal is best for this group's members? a. gain insight into unconscious factors that contribute to their illness. b. explore situations that trigger hostility and anger. c. learn to manage delusional thinking. d. demonstrate improved social skills.

d. demonstrate improved social skills. Improved social skills help clients maintain relationships with others. These relationships are important to management of the disorder. Most clients with schizophrenia think concretely, so insight development is unlikely. Not all clients with schizophrenia experience delusions.

A child diagnosed with attention deficit hyperactivity disorder (ADHD) had this nursing diagnosis: impaired social interaction related to excessive neuronal activity as evidenced by aggression and demanding behavior with others. Which finding indicates the plan of care was effective? a. has an improved ability to identify anxiety and use self-control strategies b. has increased expressiveness in communication with others. c. shows increased responsiveness to authority figures. d. engages in cooperative play with other children.

d. engages in cooperative play with other children. The goal should be directly related to the defining characteristics of the nursing diagnosis, in this case, improvement in the child's aggressiveness and play. The distracters are more relevant for a child with autism spectrum or anxiety disorder.

A disheveled client in the acute phase of major depressive disorder is withdrawn, has psychomotor retardation, and has not showered for several days. What action will the nurse take? a. bring up the issue at the community meeting. b. calmly tell the client, "You must bathe daily." c. make observations about the client's poor personal hygiene. d. firmly and neutrally assist the client with showering.

d. firmly and neutrally assist the client with showering. When clients are unable to perform self-care activities, staff must assist them rather than ignore the issue. Better grooming increases self-esteem. The client needs assistance, not simply making an observation. Calmly telling the client to bathe daily and bringing up the issue at a community meeting are punitive.

Outpatient treatment is planned for a client diagnosed with anorexia nervosa. What is the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements that should be achieved within 1 week? a. weighs self accurately using balanced scales. b. limits exercise to less than 2 hours daily. c. selects clothing that fits properly. d. gains 1 to 2 pounds.

d. gains 1 to 2 pounds. Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the client is an outpatient. The focus of an outcome would not be on the client weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority.

A nursing diagnosis for a client diagnosed with bulimia nervosa is Ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. What is the best outcome related to this diagnosis that should be achieved within 2 weeks? a. appropriately expressing angry feelings. b. verbalizing two positive things about self. c. verbalizing the importance of eating a balanced diet. d. identifying two alternative methods of coping with loneliness.

d. identifying two alternative methods of coping with loneliness. The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable.

A nurse worked with a client diagnosed with major depressive disorder, severe withdrawal, and psychomotor retardation. After 3 weeks, the client did not improve. The nurse is most at risk for what feelings? a. guilt and despair. b. over-involvement. c. interest and pleasure. d. ineffectiveness and frustration.

d. ineffectiveness and frustration. Nurses may have expectations for self and clients that are not wholly realistic, especially regarding the client's progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Nurses rarely become over-involved with clients with depression because of the client's resistance. Guilt and despair might be seen when the nurse experiences the client's feelings because of empathy. Interest is possible, but not the most likely

A client diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should engage in what behavior? a. sit close to the client. b. place an arm protectively around the client's shoulders. c. place a hand on the client's arm and exert light pressure. d. maintain a normal social interaction distance from the client

d. maintain a normal social interaction distance from the client. The client is describing phenomena that indicate personal boundary difficulties and depersonalization. The nurse should maintain appropriate social distance and not touch the client because the client is anxious about the inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic.

A student says, "Before taking a test, I feel very alert and a little restless." The nurse can correctly uses what term to document the student's experience? a. culturally influenced. b. displacement. c. trait anxiety. d. mild anxiety.

d. mild anxiety. Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the client because it promotes study and increases awareness of the nuances of questions. The incorrect responses have different symptoms.

A client diagnosed with schizophrenia has been stable for a year; however, the family now reports the client is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The client says, "My computer is sending out infected radiation beams." The nurse can correctly assess this information as an indication of what? a. the need for psychoeducation. b. medication nonadherence. c. chronic deterioration. d. relapse.

d. relapse. Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication nonadherence may not be implicated. Relapse can occur even when the client is taking medication regularly. Psychoeducation is more effective when the client's symptoms are stable. Chronic deterioration is not the best explanation.

A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child's parents have adapted to their loss? a. visiting their child's grave daily. b. maintaining their child's room as the child left it 2 years ago. c. keeping a place set for the dead child at the family dinner table. d. throwing flowers on the lake at each anniversary date of the accident.

d. throwing flowers on the lake at each anniversary date of the accident. Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest risk situations for an adjustment disorder and maladaptive grieving. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings. The other behaviors are maladaptive because of isolating themselves and/or denying their feelings. After 2 years, the frequency of visiting the grave should have decreased.