mental health exam 2

When least-restrictive methods fail for an angry, aggressive client, a physician orders restraints at 3 a.m. Per Joint Commission standards, at what time and by whom does the nurse expect an in-person client evaluation? 1. No later than 4 a.m., by a physician or an LIP 2. No later than 5 a.m., by a physician or an LIP 3. No later than 4 a.m., by a psychiatrist or the clinical nurse specialist 4. No later than 5 a.m., by the psychiatrist or a clinical nurse specialist

1

The nurse is preparing a staff development presentation to improve the screening, intervention, and referral process for clients in the geriatric community center. Which information should the nurse identify as barriers to this initiative? Select all that apply. 1. Client privacy concerns 2. Competing workload demands 3. Novice nurses 4. Staff attitude 5. Changing screening requirements

1234 Client fears about lack of privacy could be a barrier to this initiative. Clients may deny using substances, especially illegal substances, because of legal consequences. A barrier to this initiative would be competing workload demands. Less-experienced nurses or new nurses would be barriers to this initiative. Less-experienced nurses were more fearful and more likely to think mental health clients should be segregated. The staff's attitudes can be barriers to this initiative. Attitudes toward the client manifesting symptoms of mental illness or substance addiction are primary influences.

Once the nurse initiates restraints for an out-of-control 45-year-old patient, per Joint Commission standards, what must occur within 1 hour? 1. The patient must be let out of restraints. 2. A physician or other LIP must conduct an in-person evaluation. 3. The patient must be bathed and fed. 4. The patient must be included in debriefing.

2

Which of the following are symptoms of inhalant intoxication? Select all that apply. 1. Bradycardia 2. Euphoria 3. Hyperactive reflexes 4. Ataxia 5. Nystagmus

2, 4, 5

Which of the following are most appropriate when performing a nursing assessment with an individual in crisis? Select all that apply. 1. "Tell me, in your own words, what happened." 2. "What coping methods have you used, and did they work?" 3. "Describe to me what your life was like before this happened." 4. "Let's focus on the current problem." 5. "I'll assist you in selecting functional coping strategies."

1, 2, 3

____________________ is the inability to perform motor activities despite intact motor function. 1. Apraxia 2. Aphasia 3. Dementia 4. Delirium

1

Which nursing diagnosis is appropriate for a client who is unable to identify objects, confabulating, screaming, and demanding verbalizations? 1. Impaired verbal communication 2. Disturbed sensory perception 3. Situational low self-esteem; grieving 4. Disturbed thought processes; impaired memory

1 A client with a nursing diagnosis of impaired verbal communication would exhibit the following behaviors: the inability to name objects/people, loss of memory for words, difficulty finding the right word, confabulation, incoherent, screaming, and demanding verbalizations.

Beck's original concept for cognitive behavior therapy has been expanded by many theorists, but the foundation remains. Which of the following best describes the historical foundation of cognitive behavior therapy? 1. Rejection of passive listening used in psychoanalysis in favor of active, direct dialogues with clients. 2. Utilization of the psychoanalytic view of seeing depression as "anger turned inward." 3. Recognition that cognitive behavior therapy works for depression but not for other emotional disorders. 4. Cognitive behavior therapy has been the forefront of the Freudian framework of psychoanalysis.

1 Beck was trained in the Freudian psychoanalytic view of depression but began to observe a common theme of negative cognitive processing in thoughts and dreams of his depressed clients.

An advanced practice nurse is counseling a client diagnosed with generalized anxiety disorder. The nurse plans to use activity scheduling to address this client's concerns. What is the purpose of this nursing intervention? 1. To identify important areas needing concentration during therapy 2. To increase self-esteem and decrease feelings of helplessness 3. To modify maladaptive behaviors using role-play 4. To divert away from intrusive thoughts and depressive ruminations

1 In activity scheduling, the client is asked to keep a daily log of activities and rate them for mastery and pleasure to identify recurring daily patterns that can be addressed in therapy.

A client diagnosed with chronic alcohol use disorder is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to AA is most appropriate for the nurse to discuss with the client during discharge teaching? 1. After discharge, the client will attend 90 AA meetings in 90 days. 2. After discharge, the client will rely on an AA sponsor to control alcohol cravings. 3. After discharge, the client will incorporate family members in AA attendance. 4. After discharge, the client will seek appropriate deterrent medications through AA.

1 The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. AA accepts alcoholism as an illness and promotes total abstinence as the only cure

A nursing student evaluates her group project partner as irresponsible because of minimal participation in planning. When told of this situation, the nursing instructor plans to use the cognitive technique of examining the evidence. Which response by the nursing instructor exemplifies this technique? 1. "Let's look at the potential reasons why your partner has not participated." 2. "How do you define irresponsibility?" 3. "Has it occurred to you that your partner may be working on the project at home?" 4. "Are you telling me that you feel totally responsible for this project?"

1 The nursing instructor uses the technique of examining evidence to help review data that supports or contradicts the accuracy of the student beliefs.

A client has a history of daily bourbon drinking for the past 6 months. He is brought to an ED by family, who reports that his last drink was 1 hour ago. It is now midnight. When will the nurse expect this client to exhibit withdrawal symptoms? 1. Between 3 a.m. and 11 a.m. 2. Shortly after a 24-hour period 3. At the beginning of the third day 4. Withdrawal is individualized and cannot be predicted

1 This is correct. The client will begin to exhibit alcohol withdrawal between 3 a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or a reduction in heavy and prolonged alcohol use.

Which epidemiological factor related to suicide makes it difficult to determine the number of attempts that happen each year? 1. The number of suicide attempts reflects only those who enter treatment. 2. More people attempt suicide than die by suicide each year. 3. Unintentional injuries kill more people than suicide attempts each year. 4. Suicide rates consistently increased from 2000 to 2017.

1 When people who attempt suicide do not enter treatment settings, they are not counted in the number of suicide attempts, making it difficult to fully understand the number of attempts each year.

Which of the following occupational groups are at highest risk of suicide? 1. Mechanics 2. Priests 3. Teachers 4. Librarians

1 While the occupational demographic alone does not directly translate into an individual's risk, it will provide information as part of a comprehensive assessment of potentiating risk factors.

A person who demonstrates the ability to exert _________ __________ over feelings of anger would demonstrate a successful nursing outcome in the care of the client needing assistance with anger management. 1. Internal control 2. Problem-solving 3. Aggression diffusion 4. Constructive tension

1 This is correct. Demonstrating the ability to exert internal control over feelings of anger, taking responsibility for one's own feelings of anger, recognizing anger, seeking support to talk about feelings, and using the tension generated by the anger in a constructive manner are all examples of successful outcomes.

After a teenager reveals that he is gay, his parent responds by beating him. The next morning, the teenager is found to have committed suicide. Which parental grief responses should a nurse anticipate? Select all that apply. 1. "I can't believe this is happening." 2. "If only I had been more understanding." 3. "How dare he do this to me!" 4. "I'm just going to have to accept that he was gay." 5. "Well, that was a selfish thing to do."

1, 2, 3, 5 Suicide of a family member can induce several feelings in the survivors. A survivor of suicide may feel a sense of confusion. Suicide of a family member can induce several feelings in the survivors. A survivor of suicide may undergo a period of recurring self-searching Suicide of a family member can induce several feelings in the survivors. A survivor of suicide may experience anger, resentment, and rage. Suicide of a family member can induce several feelings in the survivors. A survivor of suicide may experience resentment.

Which of the following student statements about the complications of hepatic encephalopathy indicate further student teaching is needed? Select all that apply. 1. "A diet rich in protein will promote hepatic healing." 2. "This condition causes a rise serum ammonia, leading to impaired mental functioning." 3. "In this condition, blood accumulates in the abdominal cavity." 4. "Neomycin and lactulose are used in the treatment of this condition." 5. "This condition is caused by the inability of the liver to convert ammonia to urea."

1, 3

A nursing student is developing a study guide related to historical facts about suicide. Which of the following facts should the student include? Select all that apply. 1. In the Middle Ages, suicide was viewed as a selfish and criminal act. 2. During the Roman Empire, suicide was followed by incineration of the body. 3. Suicide was an offense in ancient Greece, and a common-site burial was denied. 4. During the Renaissance, suicide was discussed and viewed more philosophically. 5. Old Norse traditions set a person who committed suicide adrift in the North Sea.

1, 3, 4 In ancient Greece, suicide was considered an offense against the state, and individuals who committed suicide were denied burial in community sites (Minois, 2001). The issue of suicide changed during the Renaissance period. Although condemnation was still expected, the view became philosophical, allowing intellectuals to discuss the issue more freely. In the Middle Ages, suicide was viewed as a selfish or criminal act

A client in stage 3 Alzheimer's disease frequently wanders. Which interventions can the nurse implement to reduce the incidence of wandering and promote safety? Select all that apply. 1. Keep the client on a strict toileting schedule. 2. Allow the client a large, unrestricted area to wander. 3. Walk with the individual and redirect them back to the unit. 4. Ensure the exits are not electronically controlled. 5. Keep the client on a structured schedule of activities.

1, 3, 5

On which teaching topics would the nurse focus for a caregiver of a client with stage 5 Alzheimer's disease? Select all that apply. 1. How to assist with some ADLs, such as hygiene, dressing, and grooming 2. How to care for decubitus ulcers resulting from immobility 3. How to apply medications to compromised skin resulting from bowel and bladder incontinence 4. Tools to help reorientate the client to time and place

1, 4 With moderate cognitive decline in stage 5 Alzheimer's disease, individuals lose the ability to perform some ADLs independently, such as hygiene, dressing, and grooming, and require some assistance to manage these on an ongoing basis. In Stage 5, clients may become disoriented about place and time, but they maintain knowledge about themselves.

Which are associated with codependent behaviors among nurses? Select all that apply. 1. Overspending 2. Social isolation 3. Perfectionism 4. Personal identity 5. Denial

1,3,5

The clinic nurse is caring for a client with ulcerative colitis who has signs of depression. Which additional conditions should the nurse assess for in this client? Select all that apply. 1. Mania 2. Cardiovascular disease 3. Metabolic syndrome 4. Diabetes 5. Emphysema

1234 The nurse should assess for mania because bipolar disorder, which is characterized by bouts of depression and mania, accounts for up to 50% of all cases of depression. The nurse should assess for cardiovascular disease, as evidence has demonstrated that depression is a risk factor for cardiovascular disease. The nurse should assess for metabolic syndrome, since depression is a risk factor for metabolic syndrome. The nurse should assess for diabetes. Depression is a risk factor for diabetes.

Which of the following interventions should the nurse utilize when caring for an inpatient client who is expressing anger inappropriately? Select all that apply. 1. Maintain a calm demeanor. 2. Clearly delineate the consequences of the behavior. 3. Use therapeutic touch to convey empathy. 4. Set firm limits on the behavior. 5. Teach the client to avoid "I" statements related to expression of feelings.

124

Which of the following nursing statements exemplifies important insights to promote effective intervention with clients diagnosed with substance use disorders? Select all that apply. 1. "I am easily manipulated and need to work on this prior to caring for these clients." 2. "Because of my parent's alcoholism, I need to examine my attitude toward these clients." 3. "Drinking is legal, so the diagnosis of substance use disorder is an infringement on client rights." 4. "Opioid addicts are typically uneducated, unrefined individuals who will need a lot of education and social skills training." 5. "I can fix clients diagnosed with substance use disorders as long as I truly care about them."

124

The nurse is a manager of a unit in an acute care setting. Which actions should the nurse manager take to equip staff to address neuropsychiatric symptoms in the clients? Select all that apply. 1. Encourage the use of screening tools. 2. Provide education of staff members. 3. Keep referrals to a minimum. 4. Increase social contact with individuals with mental illness. 5. Promote defensive medicine.

124 The nurse manager should encourage the use of screening tools to address neuropsychiatric symptoms in clients. The nurse manager should provide education to help staff address neuropsychiatric symptoms in clients in a confident manner. The nurse manager should attempt to prevent stigmatization of individuals with mental illness. Research suggests that increasing positive social contact reduces stigma.

A nursing instructor is teaching about suicide in the elderly population. Which information is appropriate to include? 1. Elderly men use less-lethal means to commit suicide. 2. The second-highest rates of suicide are among those 85 years or older. 3. Suicide is the second-leading cause of death among the elderly. 4. The elderly who are single are less likely to attempt and succeed at suicide.

2

During the debriefing after a violent episode, the client states that they acted out on their perceived threat from which of the staff behaviors? 1. The staff member administered the client's prn medications when the client showed signs of "prodromal syndrome." 2. The staff member attempted to soothe the client by stroking their arm and shoulder and talking in a firm tone. 3. The staff member called for assistance and asked the ward secretary to contact the client's physician. 4. The nurse separated the client from the others with signs of "prodromal syndrome."

2

On an inpatient psychiatric unit, a restrained 16-year-old client continues to lash out verbally and threatens to abuse staff and kill himself or herself when released. Per Joint Commission standards, when does the nurse expect the physician or LIP to renew the client's restraint order? 1. Within 1 hour of the original restraint order 2. Within 2 hours of the original restraint order 3. Within 3 hours of the original restraint order 4. Within 4 hours of the original restraint order

2

The triage nurse notes a client with a history of alcohol use disorder has an elevated heart rate, palpitations, shortness of breath, and a dry cough. Which best explains the client's symptoms? 1. Alcoholic myopathy 2. Alcoholic cardiomyopathy 3. Esophagitis 4. Portal hypertension

2

hich nursing approach is likely to be most therapeutic when dealing with a newly admitted, hostile, suspicious client? 1. Place a hand on the client's shoulder and state, "I will help you to your room." 2. Slowly and matter-of-factly state, "I am your nurse and I will show you to your room." 3. Firmly set limits by stating, "If your behavior does not improve, you will be secluded." 4. Smile and state, "I am your nurse. When do you want to go to your room?"

2

A nurse recently admitted a client to an inpatient unit after a suicide attempt. The health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this client's safety upon discharge? 1. Provide a 6-month supply of Elavil to ensure long-term compliance. 2. Provide a 3-day supply of Elavil with refills given at follow-up appointments. 3. Provide a pill dispenser and a smart-phone application as a reminder system. 4. Provide education regarding the avoidance of foods containing tyramine.

2 Amitriptyline (Elavil) is a tricyclic antidepressant. Tricyclic antidepressants have a narrow therapeutic range and can be used to commit suicide

The predisposing factor, anger turned inward, is a psychological theory of Freud's proposing which of the following? 1. The strength of a person's intention to die is as significant as his or her feelings of hopelessness. 2. Suicide occurs because of an earlier repressed desire to kill someone else. 3. Suicide is a way to prevent public humiliation following a social defeat. 4. Suicide occurs when a person feels separate from the mainstream of society

2 Freud believed that suicide was a response to intense self-hatred. The anger originated toward a love object but was ultimately turned inward against the self.

A client is diagnosed with an anxiety disorder. The nurse counselor recommends the behavioral technique of reciprocal inhibition. The client asks, "What's that?" Which is the best nursing reply? 1. "At the beginning of this intervention, a contract will be drawn up explicitly stating the behavior change agreed upon." 2. "By introducing an adaptive behavior that is mutually exclusive to your maladaptive behavior, we will expect subsequent behavior to improve." 3. "Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety." 4. "In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate."

2 Reciprocal inhibition decreases or eliminates an undesired behavior by introducing a more adaptive behavior that is incompatible with the undesired behavior.

An adolescent client was recently admitted to the psychiatric unit because of impulsivity and acting-out behavior at school. Which nursing action should the nurse implement first? 1. Redirect the client to activities to decrease stress. 2. Explain the unit rules and consequences of breaking the rules. 3. Place the client on close observation to ensure a trusting relationship. 4. Administer an antianxiety medication.

2 The first nursing action is to explain the unit rules and the consequences of breaking the rules to influence the adolescent's behavior. Operant conditioning theory asserts that stimuli (environmental events) interact with and influence an individual's behavior.

After years of dialysis, an 84-year-old states, "I'm exhausted, depressed, and done with these attempts to keep me alive." Which question should the nurse ask the spouse when preparing a discharge plan of care? 1. "Have there been any changes in your spouse's appetite or sleep?" 2. "How often is your spouse left alone?" 3. "Has your spouse been following a diet and exercise program consistently?" 4. "How does your spouse cope with illness?"

2 The term following hospital discharge is a high-risk period, and the client has numerous risk factors for suicide: exhaustion, depression, and a chronic medical illness. A detailed safety plan should be developed that includes preventing the client from being left alone.

The spouse of an alcoholic comes to the clinic and asks for some medication to help the client stop drinking. The spouse states that there is a drug given to help stop drinking by making them sick after ingesting alcohol. Which of the following is the most appropriate response to this request? 1. "This may work, as it has been a form of eliminating behavior with a more-adaptive behavior." 2. "This would be a discussion with the individual who wishes to stop drinking by replacing the euphoric feeling with a severe punishment." 3. "I am sure that the therapist can prescribe this and you can add it to your spouse's food." 4. "Have you tried to use a written contract with your spouse first? The side effects of the medication are dangerous."

2 This is a form of overt sensitization, or aversion therapy, that produces unpleasant consequences. This disulfiram (Antabuse) is given to individuals who wish to stop drinking. Further discussion is necessary, as the client must agree to this treatment.

The nurse is caring for an older adult client with an NCD who becomes agitated. Which intervention by the nurse is appropriate? Select all that apply. 1. Demand the client attend a group activity session. 2. Administer an antipsychotic medication as prescribed. 3. Restrain the client immediately. 4. Encourage doll therapy. 5. Attempt to reason with the client. 6. Perform relaxation techniques.

2, 4, 6

Nursing students were provided serum blood levels of 30 different clients and were asked to identify those most at risk for a future suicide attempt based on the laboratory levels alone. Which two of the following factors should the students focus on for statistically significant biological factors? Select two choices. 1. Serotonin 2. Fish oil nutrients 3. Cytokines 4. 5-hydroxyindole acetic acid (5-HIAA)

2,3 Fish oil nutrients, including omega-3, was one of two biological factors that have statistical significance for a future suicide attempt. Cytokines were one of two biological factors that have statistical significance for a future suicide attempt.

A client diagnosed with paranoid schizophrenia has a history of aggravated assault. The nurse assigns "Risk for other-directed violence" as the client's priority nursing diagnosis. Which is an appropriate, correctly written outcome for the client? 1. The client will not verbalize anger or hit anyone. 2. The client will verbalize anger rather than hit others. 3. The client will not inflict harm on others during this shift. 4. The client will be restrained if any abuse is observed during this shift.

3

A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "I just need to work harder to get him there on time." Which is the appropriate nursing response? 1. "Why do you assume responsibility for his behaviors?" 2. "Codependency is a typical behavior of spouses of alcoholics." 3. "Your husband needs to deal with the consequences of his drinking." 4. "Do you understand what the term enabler means?"

3

During group therapy, a client diagnosed with alcohol use disorder states, "I would not have boozed it up if my spouse hadn't been nagging me all the time to get a job. She never did think that I was good enough for her." How should the nurse interpret this statement? 1. The client is using denial by avoiding responsibility. 2. The client is using displacement by blaming his spouse. 3. The client is using rationalization to excuse his alcohol dependence. 4. The client is using reaction formation by appealing to the group for sympathy.

3

The client states, "I get into trouble because I respond violently without thinking. That usually gets me into a mess." Which nursing reply is most therapeutic? 1. "Everybody loses their temper. It's good that you know that about yourself." 2. "I'll bet you have some interesting stories to share about overreacting." 3. "Let's explore methods to help you stop and think before taking action." 4. "It's good that you are showing readiness for behavioral change."

3

Yelling, name-calling, hitting others, and temper tantrums as expressions of anger are all evidence supporting which nursing diagnosis? 1. Risk for self-directed or other-directed violence related to socioeconomic factors 2. Anger related to dysfunctional relationships and ineffective coping skills 3. Ineffective coping related to negative role modeling and dysfunctional family systems 4. Complicated grieving related to a loss of support system

3

Which datum indicates a suicidal client is participating in a safety plan? 1. Compliance with antidepressant therapy 2. A mood rating of 9/10 3. Disclosing a plan for suicide to staff 4. Expressing feelings of hopelessness to the nurse

3 A degree of the responsibility for the suicidal client's safety is given to the client. When a client shares with staff a plan for suicide, the client is participating in a plan for safety by communicating thoughts of self-harm that would initiate interventions to prevent suicide. 4. This is incorrect. Expressing feelings of h

The student comes in to the instructor's office and reports that they wish to drop out of nursing school due to the overwhelming work. The instructor advises the student to write assignments and due dates on a calendar to help break down what needs to be done and when. What technique is the instructor using? 1. Activity scheduling 2. Distraction 3. Graded task assignments 4. Behavioral rehearsal

3 Graded task assignments are used to break down the task into subtasks that the client can complete one step at a time. Using a calendar with the assignments and due dates may help the student/client increase self-esteem and decrease feeling of helplessness.

Which of the following is considered a fact about suicide? 1. Drug overdose is the leading cause of death among suicide victims. 2. Once a person is considered suicidal, he or she should be viewed as suicidal indefinitely. 3. Most suicidal people have ambivalent feelings regarding living or dying.

3 It is a myth that you cannot stop a suicidal person. Most suicidal people are ambivalent about their feelings regarding living or dying. Most are "gambling with death" and see it as a cry for someone to save them.

A nursing student states, "The instructor gave me a failing grade on my research paper. I know it's because the instructor doesn't like me." Which cognitive error does the nurse recognize in this student's statement? 1. Dichotomous thinking 2. Catastrophic thinking 3. Magnification 4. Overgeneralization

3 Magnification is exaggerating the negative significance of an event.

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility? .. 1. By asking directly if the client has ever had a problem with alcohol 2. By using the Clinical Institute Withdrawal Assessment scale 3. By using a screening tool, such as the CAGE questionnaire 4. By referring the client for physician evaluation

3 The CAGE questionnaire is a screening tool used to determine whether the individual has a problem with alcohol. This questionnaire is composed of four simple questions. Scoring two or three "yes" answers strongly suggests a problem with alcohol.

According to the Three-Step Theory, when strong, active suicide ideation is present: 1. An attempt occurs usually within 3 to 6 months of the initial ideation. 2. Pain management usually prevents escalation to an attempt. 3. It leads to an attempt only if the individual has the capacity to make an attempt. 4. Connectedness to family typically resolves any attempt.

3 The Three-Step Theory mentions that when a strong, active ideation is present, it leads to an attempt if the capacity to make the attempt is present.

A client is experiencing progressive changes in memory that have interfered with personal, social, and occupational functioning. The client exhibits poor judgment and has a short attention span. The nurse recognizes these as classic signs of which condition? 1. Mania 2. Delirium 3. NCD 4. Parkinsonism

3 The client is exhibiting signs of an NCD, which is characterized by impairment in abstract thinking, judgment, and impulse control. Behavior may be uninhibited and inappropriate.

A client diagnosed with alcohol use disorder joins a community 12-step program and states, "My life is unmanageable." Which of the following indicates the nurse's interpretation of the client's statement? 1. The client is using minimization as an ego defense. 2. The client is ready to sign an AA contract for sobriety. 3. The client has accomplished the first of 12 steps advocated by AA. 4. The client has met the requirements to be designated as an AA sponsor.

3 The first step of the AA program is, "We admitted we were powerless over alcohol—that our lives have become unmanageable."

During hospitalization, an attention-seeking client has repeatedly cut herself. After threatening to cut herself again, the nurse states, "Here are some Band-Aids so you won't bleed on the sheets." Which is the underlying reason for this nurse's response? 1. The nurse is using an aversive stimulus in response to the client's manipulative cutting behavior.2. The nurse is using negative reinforcement in response to the client's behavior. 3. The nurse is working to extinguish the client's manipulative behavior. 4. The nurse lacks empathy for the client's recurring self-injurious behavior.

3 The nurse's goal is extinction of the client's manipulative, attentionseeking behavior. Extinction is the gradual decrease in frequency or disappearance of a response when a positive reinforcement is withheld.

Upon admission for symptoms of alcohol withdrawal, a client states, "I haven't eaten in 3 days." Assessment reveals blood pressure of 170/100 mm Hg, pulse of 110 bpm, respirations of 28 breaths/min, and a temperature of 97°F with dry skin, dry mucous membranes, and poor skin turgor. Which of the following is the priority nursing diagnosis? 1. Knowledge deficit 2. Denial 3. Deficient fluid volume 4. Ineffective individual coping

3 The priority nursing diagnosis is deficient fluid volume. A decrease in fluid volume during alcohol withdrawal can be due to a lack of intake as well as symptoms of nausea and vomiting. The client's data supports deficient fluid volume with the dry skin, dry mucous membranes, poor skin turgor, and elevated bp and hr

On the first day of a client's alcohol detoxification, which nursing intervention is the priority? 1. Encourage the client to attend 90 Alcoholics Anonymous (AA) meetings in 90 days. 2. Educate the client about the biopsychosocial consequences of alcohol abuse. 3. Administer ordered chlordiazepoxide (Librium) in a dosage per protocol. 4. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

3 The priority nursing intervention is to administer chlordiazepoxide (Librium) per protocol. The benzodiazepine chlordiazepoxide (Librium) is often used for substitution therapy in alcohol withdrawal. Substitution therapy is used to reduce life-threatening effects of the rebound stimulation of the CNS that occurs during alcohol withdrawal.

Which nursing student statement requires further teaching regarding care for the client with NCD experiencing hallucinations? 1. "I will assess for side effects of medications that could cause hallucinations." 2. "My client wears a hearing aid. I need to ensure it is working properly." 3. "If I am not experiencing the hallucination, then it is likely the client is not either." 4. "I took the mirror off the wall because the client was seeing a false image."

3 This statement requires further teaching. Just because the student cannot see or hear what the client sees or hears does not mean it is not real to the client.

A client diagnosed with brief psychotic disorder is pacing the milieu and occasionally punches the wall. Which is the initial nursing action? 1. Assertively instruct the client to stop punching the wall. 2. Encourage the client to write down feelings in a journal.3. With the help of staff, initiate seclusion protocol. 4. Ensure adequate physical space between the nurse and the client.

4

A nurse in the ED assesses a 17-year-old client exhibiting symptoms of opioid intoxication. Which should be the nurse's first action? 1. Contact the parents. 2. Administer oxygen. 3. Open the crash cart. 4. Administer naloxone (Narcan)

4

After the client's restraints are removed, the staff discusses the incident and establishes guidelines for the client's return to the therapeutic milieu. Which unit procedure is the staff implementing? 1. Milieu reenactment 2. Treatment planning 3. Crisis intervention 4. Debriefing

4

The nurse is interviewing a client in an outpatient drug treatment clinic. To promote success in the recovery process, which initial outcome should the nurse expect the client to accomplish? 1. The client will identify one person to turn to for support. 2. The client will give up all old drinking buddies. 3. The client will be able to verbalize the effects of alcohol on the body. 4. The client will correlate life problems with alcohol use.

4

The nurse is providing care to a client who has become emotionally labile with paranoia after losing their career and home due to a motor vehicle accident. The nurse recognizes that the client is at what phase of crisis development? 1. Phase 1 2. Phase 2 3. Phase 3 4. Phase 4

4

Which client statement indicates a knowledge deficit related to substance use? 1. "Although it's legal, alcohol is one of the most widely abused drugs in our society." 2. "Tolerance to heroin develops quickly." 3. "Flashbacks from lysergic acid diethylamide (LSD) use may reoccur suddenly." 4. "Everyone smokes marijuana. It's harmless."

4

Which medication orders should the nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines? 1. Haloperidol (Haldol) and fluoxetine (Prozac) 2. Carbamazepine (Tegretol) and donepezil (Aricept)3. Disulfiram (Antabuse) and lorazepam (Ativan) 4. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

4

Thomas Joiner's interpersonal theory of suicide proposes which of the following? 1. An interruption in the customary norms of behavior instills fears of being without support. 2. Impulsivity is elevated in people who have made suicide attempts. 3. Allegiance is so strong to a group that the individual will sacrifice their life for the group. 4. The concept of suicide ideation and suicide attempts are distinct processes.

4 . Joiner's theory introduces the concept that suicide ideation and suicide attempts need to be understood as distinct processes.

When seeking special privileges, a child always chooses to ask the mother rather than the father. The father is more apt to disagree with the child's requests, whereas the mother usually consents. Which component of operant conditioning explains the child's choice? 1. Conditioned stimuli 2. Unconditioned stimuli 3. Aversive stimuli 4. Discriminative stimuli

4 Discriminative stimuli are under an individual's control. The child can discriminate between stimuli and can predict with assurance that asking the mother (not the father) will result in a desired response

During a one-to-one session, the client states, "Nothing will ever get better" and "Nobody can help me." Which nursing diagnosis is most appropriate for the nurse to assign at this time? 1. Powerlessness related to (R/T) altered mood as evidenced by (AEB) client statements 2. Risk for injury R/T altered mood AEB client statements 3. Risk for suicide R/T altered mood AEB client statements 4. Hopelessness R/T altered mood AEB client statements

4 The client's statements indicate the problem of hopelessness.