Mental Health - NCLEX-RN Exam
The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1."You need to stop that behavior now." 2."You will need to be placed in seclusion." 3."You seem restless; tell me what is happening." 4."You will need to be restrained if you do not change your behavior."
3."You seem restless; tell me what is happening." The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.
The nurse should include which information in the medication teaching plan for a client diagnosed with schizophrenia? 1.Coffee, tea, and soda consumption should be limited. 2.If the client is compliant, the relapse of symptoms will never occur. 3.Psychotropic medications may cause mild cardiovascular symptoms. 4.Most schizophrenic clients are able to taper off their medications eventually.
1.Coffee, tea, and soda consumption should be limited. Caffeine can inhibit the action of psychotropic medications commonly prescribed for schizophrenia. Most clients will require continuous medication therapy to manage their symptoms. Although medication compliance is a strong factor in minimizing the reoccurrence of relapses, relapse could occur. Cardiovascular symptoms are not typical side effects of psychotropic medications.
The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1.Setting limits on the client's behavior 2.Asking the client to leave the group session 3.Asking another nurse to escort the client out of the group session 4.Telling the client that they will not be able to attend any future group sessions
1.Setting limits on the client's behavior Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client's behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client's right to receive treatment and is a threatening action.
The client says to the nurse, "I wish you would just be my friend." Which is the appropriate response by the nurse? 1."I am your friend." 2."Our relationship is a therapeutic and helping one." 3."I can't be your friend. I'm the nurse, and you're the client." 4."You have plenty of friends. You don't need me to be your friend, too."
2."Our relationship is a therapeutic and helping one." Nurses may struggle with requests by clients to "be my friend." When this occurs, the nurse should make it clear that the relationship is a therapeutic and helping one. This does not mean that the nurse is not friendly toward the client at times. It does mean, however, that the nurse follows the stated guidelines regarding a therapeutic relationship. The remaining options are inappropriate, particularly in their failure to define the relationship.
During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primary characteristics of bulimia? 1.Refusing to eat and excessive exercising 2.Eating only vegetables and fruits and fasting 3.Hoarding of food and difficulty controlling food intake 4.Eating a lot of food in a short period of time and misuse of laxatives
4.Eating a lot of food in a short period of time and misuse of laxatives Eating binges and purging are the characteristic that would be seen in bulimia. Eating only certain types of foods may reflect a preference but does not indicate bulimia. Bulimic persons usually do not refuse to eat; rather, they binge and purge. Hoarding of food may indicate another problem.
The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 1."I no longer feel that I deserve the beatings my husband inflicts on me." 2."My attendance at the meetings has helped me to see that I provoke my husband's violence." 3."I enjoy attending the meetings because they get me out of the house and away from my husband." 4."I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics."
1."I no longer feel that I deserve the beatings my husband inflicts on me." Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. Option 2 is incorrect because the nonalcoholic partner should not feel responsible when the spouse loses control. Option 3 indicates that the group is viewed as an escape, not as a place to work on issues. Option 4 indicates that the wife remains codependent.
A client diagnosed with depression is scheduled to receive three sessions of electroconvulsive therapy. The nurse should tell the client that he or she will likely start to see improvement in approximately what time frame? 1.1 week after the 3rd treatment session 2.3 weeks after the treatment sessions begin 3.Midway between the 2nd and 3rd treatment session 4.8 weeks after the treatment sessions are completed
1.1 week after the 3rd treatment session Health care providers generally administer electroconvulsive therapy (ECT) treatments three times a week, with an average series including 8 to 12 treatments. After three sessions of ECT, the client should start to demonstrate improvement in 1 week. The remaining options are incorrect.
A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? 1.Avoidant 2.Borderline 3.Schizotypal 4.Obsessive-compulsive
1.Avoidant The avoidant personality disorder is characterized by social withdrawal and extreme sensitivity to potential rejection. The person retreats to social isolation. Borderline personality disorder is characterized by unstable mood and self-image and impulsive and unpredictable behavior. Schizotypal personality disorder is characterized by the display of abnormal thoughts, perceptions, speech, and behaviors. Obsessive-compulsive personality disorder is characterized by perfectionism, the need to control others, and a devotion to work.
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1.Move the client next to the nurses' station. 2.Use an indirect light source and turn off the television. 3.Keep the television and a soft light on during the night. 4.Play soft music during the night, and maintain a well-lit room.
2.Use an indirect light source and turn off the television. Provision of a consistent daily routine and a low stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action.
The nurse is planning to formulate a psychotherapy group. Several clients are interested in attending the session. The nurse plans the group, based on which management principle? 1.Members should be of the same gender. 2.The group will decide the focus of the sessions. 3.The group should be limited to no more than 10 members. 4.The focus of the group will determine when the group will meet.
3.The group should be limited to no more than 10 members. The ideal number of clients in a psychotherapy group ranges from 7 to 10. Having more than 10 members is not recommended because the group will subdivide, which is counterproductive. Too large a group also can create more opportunities for acting out as opposed to working through issues. None of the other options is necessarily true.
