MH: Psychobiological Disorders

A school nurse is asked to present an educational program on attention deficit-hyperactivity disorder (ADHD) to the teaching staff of an elementary school. The nurse should emphasize that this disorder:

Affects 3% to 7% of the school-age population

A depressed, withdrawn female client exhibits sadness through nonverbal behavior. The nurse should plan to help the client to:

Cope with painful feelings by sharing them.

A female client with obsessive-compulsive disorder has become immobilized by her elaborate handwashing and walking rituals. The nurse recalls that the basis of obsessive-compulsive disorder is often feelings of:

Anxiety and guilt Ritualistic behavior seen in this disorder is aimed at controlling feelings of anxiety and guilt by maintaining an absolute set pattern of action. Although the person with an obsessive-compulsive disorder may be angry and hostile, the feelings of anger and hostility do not precipitate the rituals. Although the person with an obsessive-compulsive disorder may be embarrassed and ashamed by the ritual, the basic feelings precipitating the rituals are usually anxiety and guilt.

The nurse recalls that the major defense mechanism used by an individual with a phobic disorder is:

Avoidance The person transfers anxieties to activities or objects, usually inanimate objects, which are then avoided to decrease anxiety. Splitting is the compartmentalization of opposite affective states and the inability to integrate the positive and negative aspects of others or self. Regression, the return to an earlier, more comfortable level of development, is not the defense mechanism used by someone with a phobia. Conversion, the transfer of a mental conflict to a physical symptom, is not the defense mechanism used by someone with a phobia.

The nurse is working with a client who talks freely about feeling depressed. During the interaction the client states, "Things will never change." What findings support the nurse's conclusion that the client is experiencing hopelessness? Select all that apply.

Bouts of crying Self-destructive acts Feelings of worthlessness Clients who feel depressed and hopeless also tend to show their depression and hopelessness physically through crying. Clients who feel depressed and hopeless may try to commit suicide to end the emotional pain they are suffering. Clients who feel depressed and hopeless also tend to express feelings of worthlessness. Preoccupation with delusions is associated with clients with a diagnosis of schizophrenia, not depression. Clients who feel depressed and hopeless tend to be socially withdrawn and to not have the physical or emotional energy required for intense interpersonal relationships.

A client with the diagnosis of obsessive-compulsive disorder uses paper towels to open doors to avoid touching dirty doorknobs. How should the nurse respond initially to this behavior?

By allowing the behavior for the time being A therapeutic relationship is easier to establish when anxiety is eased; the use of paper towels may ultimately facilitate communication. Preventing the client from using towels may increase anxiety further, thus hindering the development of a therapeutic relationship. Telling the client that the towels are dirty reinforces the use of dirt as a defense against real feelings and will worsen the client's anxiety. Removing the paper towels from the area may increase anxiety further, thereby hindering the development of a therapeutic relationship.

Which suicide method is the least lethal?

Ingesting pills

A nurse recalls that the environment is important when caring for a client with the diagnosis of bipolar II disorder with hypomanic episodes. What should the nurse do when caring for clients with this disorder?

Provide a quiet atmosphere by placing the client in a private room.

An older client's family tells the nurse that the client has suffered some memory loss in the past few years. They say that the client is sensitive about not being able to remember and tries to cover up this loss to avoid embarrassment. When attempting to increase the client's self-esteem, the nurse should try to avoid discussing events that require memory of the client's:

Recent days Clients with dementia have the greatest loss in the area of recent memory. Memory of remote events (e.g., married life, working years, young adulthood) usually remains fairly intact.

A man has completed an alcohol detoxification program and is setting goals for rehabilitation. When setting goals it is important for this client to understand the need to:

Restructure his life without alcohol. Clients must learn new lifestyles and coping skills to maintain sobriety. Planning to avoid people who drink is an unrealistic, unattainable plan. Accepting that he is a fragile person is judgmental, negative thinking that will lower self-esteem. Abstinence is essential; social drinking is not an option.

A client is exhibiting a pattern of withdrawn behavior. The nurse anticipates that this type of behavior will eventually produce feelings of:

Loneliness A pattern of withdrawn behavior prevents the individual from reaching out to others for sharing; the isolation produces feelings of loneliness. Feelings of anger may result in withdrawal, but withdrawal does not produce feelings of anger. Feelings of paranoia may result in withdrawal, but withdrawal does not produce these feelings. Repression is an unconscious defense whereby the individual excludes ideas, feelings, or situations from the conscious level of thought; this does not result from withdrawal.

A nurse is assessing an adolescent client with the diagnosis of schizophrenia, undifferentiated type. Which signs and symptoms should the nurse expect the client to experience?

Loosened associations and hallucinations Loosened associations and hallucinations are the primary behaviors associated with a thought disorder such as schizophrenia. Paranoid delusions and hypervigilance are more common in paranoid-type schizophrenia than in the undifferentiated type. Depression and psychomotor retardation are not characteristic of schizophrenia. Ritualistic behavior and obsessive thinking are generally associated with obsessive-compulsive disorders, not schizophrenia.

A client who has been admitted with a diagnosis of schizophrenia says to the nurse, "Yes, it's March. March is Little Women. That's literal, you know." These statements illustrate:

Loosening of associations Loose associations are thoughts that are presented without the logical connections that are usually necessary for the listener to interpret the message. Echolalia is the purposeless repetition of words spoken by others or repetition of overheard sounds. Neologisms are new meaningless words coined by the client or new, unique meanings given to old words. Flight of ideas is the rapid skipping from one thought to another; these thoughts usually have only superficial or chance relationships.

A 5-year-old with an attention deficit-hyperactivity disorder (ADHD) exhibits a short attention span and demonstrates intermittent head-banging and hair-pulling, as well as excessive motor activity. What is the priority nursing objective for this child?

Maintaining safety Excessive motor activity with intermittent head-banging and hair-pulling is self-destructive behavior that may result in injury; prevention of self-injury has the highest priority. Facilitating sleep, promoting body image, and increasing nutritional intake are not the most important nursing objectives in light of the data presented; prevention of self-injury is primary.

A nurse is caring for a client with the diagnosis of bulimia nervosa. The nurse understands that individuals with bulimia use food to:

Meet emotional needs. Clients with bulimia eat to blunt emotional pain because they frequently feel unloved, inadequate, or unworthy; purging is precipitated to relieve feelings of guilt for binging or out of fear of obesity. The binging and purging are usually done alone and in secret. Clients with bulimia often feel out of control and perform their behaviors in secret. A protest against growing up is one of the psychodynamic theories regarding anorexia nervosa, not to bulimia nervosa.

A nurse is caring for a client who is delusional and talking about people who are plotting to do harm. The staff members notice that the client is pacing more than usual, and the primary nurse concludes that the client is beginning to lose control. What is the most therapeutic nursing intervention?

Moving the client to a quiet place Clients losing control feel frightened and threatened; they need external controls and a reduction in external stimuli. The client will be unable to sit at this time; the agitation is building. Encouraging the client to use a punching bag is helpful for pent-up aggressive behavior but not for agitation associated with delusions. The pacing is not adequately relieving the client's agitation. Another intervention is needed to prevent acting-out behaviors.

A client with schizophrenia repeatedly says to the nurse, "No moley, jandu!" The nurse determines that the client is exhibiting:

Neologism Neologisms are words that are invented and understood only by the person using them. Echolalia is the verbal repeating of exactly what is heard. Concretism is a pattern of speech characterized by the absence of abstractions or generalizations. Perseveration is a disturbed system of thinking manifested by repetitive verbalizations or motions or by persistent repetition of the same idea in response to different questions.

A mother calls the emergency department and speaks to a nurse. Her 16-year-old daughter has just been found in her bedroom cutting her wrists. The mother says, "They're just superficial cuts; the old ones have healed just fine." The mother states that the daughter has had three previous psychiatric admissions for suicide attempts and says that "this situation is pretty much like the other times. I'm not sure whether I should bring her in tonight or tell her doctor about what happened at her next appointment, later this week." The best reply by the nurse is:

"You should call 911 now and let them know that your daughter has made a suicide attempt and needs help." No matter how irritated a family member may be or how trivial the suicide attempt might seem, the attempt must be taken seriously. The daughter is communicating that she is unable to find a way out of a desperate situation or state of mind. The physician should be made aware of the situation, but the daughter still requires immediate attention and evaluation by trained medical personnel.

A client on a psychiatric unit who has been acting out for several weeks approaches the nurse and says, "I'm really sorry about how I've acted. I'll bet everyone thinks I'm an idiot." What is the best initial response by the nurse?

"You're wondering how others will react to you now." Observing that the client is worried about how others will perceive her best clarifies the client's major concern and encourages discussion of feelings. The nurse cannot legitimately speak for other clients; saying what other clients are thinking may increase the client's anxiety about the future. Saying that everyone feels foolish sometime is an ineffective use of empathy because it cuts off further communication; it also indicates that the nurse agrees that the client acted foolishly. Saying that everyone realized that the client was struggling is inappropriate because the nurse cannot legitimately speak for other staff members and clients.

On the fifth day of hospitalization the nurse notes that a depressed client remains lying on her bed when the clients are called to the dining room for lunch. What should the nurse do to encourage the client to eat?

Offer to accompany the client to the dining room. The client will be most likely to eat if accompanied and encouraged by an individual with whom a trusting relationship has been established. Having a lunch tray sent to the client's room will not encourage the client to eat and will promote isolation. Explaining that all clients are expected to go to the dining room for meals will be ineffective at this time; the client is too introspective to care. The client is not interested in maintaining health and is not ready for any teaching.

A client has just awakened from her first electroconvulsive therapy (ECT) treatment. What is the most appropriate initial intervention by the nurse?

Orienting the client to time and place and explaining that the treatment is over Clients are confused when they awaken after ECT. They have loss of recent memory, so it is important to orient them to time, place, and situation. The client should be monitored until vital signs are stable and the client is alert, oriented, and able to walk without assistance; this generally takes 1 to 3 hours. Sitting the client up may be done later action if the client asks for food. Vital signs are monitored until stable; they may become stable before the client is fully awake.

A client with the diagnosis of schizophrenia becomes extremely agitated, and the health care provider prescribes ziprasidone (Geodon) 15 mg intramuscularly stat. The medication package is labeled "20 mg/mL." How many milliliters of ziprasidone solution should the nurse administer? Remember to include the leading zero and take your answer to two decimal places. ___ mL

0.75 mL

A 10-year-old child in whom autism was diagnosed at the age of 3 attends a school for developmentally disabled children and lives with his parents. The child has frequent episodes of self-biting and head-banging and needs help with feeding and toileting. The priority nursing goal for this child is:

Remaining safe from self-inflicted injury The priority is safety; the child must be protected from self-harm. Repetitive behaviors are comforting, and unless they are harmful their limitation is not a priority. Although feeding independently is a basic need that may be achieved, it is not the priority. Children who need help with toileting are not necessarily incontinent, and it is not the priority.

An adolescent on a mental health unit becomes hyperactive. In which activity should the nurse encourage the client to become involved?

Sanding and assembling wooden bookends

An executive assistant experiences an overwhelming impulse to count and arrange the rubber bands and paper clips in his desk. The client feels that something dreadful will occur if the ritual is not carried out. Considering the client's symptoms, the nurse concludes that rituals:

Serve to control anxiety resulting from unconscious impulses Serving to control anxiety resulting from unconscious impulses is the psychoanalytical explanation for the development of obsessive-compulsive symptomatology. Compulsive rituals commonly result in interference with activities of daily living and the individual becomes dysfunctional; the need to perform rituals cannot be controlled. A displacement of general anxiety onto an unrelated specific fear is the general description of phobias. The client is unable to consciously stop the behavior because anxiety will become overwhelming if the ritualistic defense is not used. The behavior is not overwhelming because it limits anxiety.

What is the school nurse's most important action when monitoring an adolescent who has just returned to high school after a suicide attempt?

Speaking with the adolescent regarding any feelings he has about returning to school Speaking with the adolescent regarding any feelings he has about returning to school shows the adolescent that the nurse is available and is interested and concerned. Observing the adolescent with frequent summonses to the health office will draw too much attention to the adolescent; also, it is demeaning. Requesting that teachers and friends report any changes in behavior will place responsibility on others and may interfere with the adolescent's relationship with them. Also, it violates the adolescent's right to privacy. Telling the teachers what happened and having them ask whether there are any problems violates the adolescent's right to privacy.

A nurse is conducting an initial assessment of a client with the diagnosis of paranoid schizophrenia. Which assessment is the major concern for the nurse?

Suspicious feelings Suspicious feelings may interfere with the development of a trusting nurse-client relationship. Also, a person who is suspicious may protect him- or herself through the use of verbal or physical aggression. Safety is a priority, as is the development of a therapeutic nurse-client relationship. Continuous pacing is not a problem because the nurse can accompany a pacing client. Lack of love for parents is not an initial concern. Disregard for the feelings of others is not an initial concern unless it jeopardizes the safety of others. There are no data indicating that it is a safety issue.

A male client with paranoid schizophrenia wraps his legs in toilet paper, believing that this will protect him from deadly germs contaminating the floor. What is the best nursing intervention?

Talking with the client about anxiety that focuses on health Exploring the feelings expressed in the delusion is more therapeutic than discussing specific content. Limiting the client's access to toilet paper may frustrate the client, who will probably seek other ways to "protect" himself. Providing the client with antimicrobial soap reinforces the client's delusion about deadly germs. Trying to talk this client out of his delusion will not be effective and may precipitate hostility.

A client is admitted to the mental health clinic for treatment of an obsessive-compulsive disorder that impairs ability to work outside the home. What should the nurse consider about the client's behavior when developing a plan of care?

The client knows that the behavior is illogical but is unable to stop it. The client using ritualistic behavior recognizes on a conscious level that the ritual is unrealistic, but because the ritual is used to control unconscious thoughts or feelings the client is unable to stop performing the act. Clients are aware they are repeating the behavior, but they are unable to stop. Although the culture may affect the particular form a ritual may take, the need for ritualistic behavior arises from an internal conflict. Because the behavior is controlled by the unconscious, encouragement in any form will not help stop the ritual.

A nurse works in a crisis intervention center. A woman who has experienced sexual abuse comes in and says, "I've got to talk to someone or I'll go crazy. I shouldn't have dated him." What is most important for the nurse to identify after initially assessing the client's physical condition?

support system Identification of a client's support system and relationships is a priority if the victim is to be helped after the immediate crisis is over. Sexual background and ability to relate the facts may eventually be of value, but at this time they are irrelevant in the assessment of the client's current condition and needs. Knowledge of sexual assault terminology is not necessary for care to be provided.

A client with a history of drug abuse begins group therapy. After attending the first meeting the client says to the nurse, "It helps to know that I'm not the only one with this type of problem." What concept does this statement reflect?

universality Universality is the sense that one is not alone in any situation; one purpose of group therapy is to share feelings and gain support from others with similar thoughts and feelings. Altruism in group therapy is giving support, insight, and reassurance to others, which eventually promotes self-knowledge and growth. Catharsis involves group members relating to one another through the verbal expression of negative and positive feelings. Transference occurs when a client unconsciously assigns to the therapist feelings and attitudes originally associated with another important person in the client's life.

A client's parents ask about the treatment of their son who recently found to have schizophrenia. Before responding, the nurse recalls that:

Drug therapy, although it does not eliminate the underlying problem, reduces the symptoms of acute schizophrenia. Psychoactive drugs have been shown to be capable of interrupting the acute psychiatric process, making the client more amenable to other therapies. Electroconvulsive therapy may be effective in treating depressed clients. Family therapy is effective but is a long-term, costly proposition; signs and symptoms must be reduced before the client can participate. Clients with schizophrenia usually have little insight into their problems. Confronting the client through insight therapy will increase anxiety.

A female client with bipolar I disorder, manic episode, is admitted to the mental health unit of a community hospital. When developing an initial plan of care for this client, the nurse should plan to:

Encourage increased nutritional intake. The client in a manic episode of the illness often neglects basic needs; these needs are a priority to ensure adequate nutrition, fluid, and rest. The hyperactivity of mania creates an increased need for calories. Although the client needs to expend excess energy, physical exhaustion and dehydration are real possibilities during the manic episode of the illness. Isolating her from her peers is counterproductive and punitive. The client is unable to actively participate in group activities at this time.

A woman with bipolar disorder, manic episode, has been spending thousands of dollars on clothing and makeup. She has been partying in bars every night and rarely sleeps or eats. The nurse in the outpatient clinic, knowing that this client rarely eats, recognizes that her eating problems most likely result from her:

Excessive physical activity During a manic episode hyperactivity and the inability to sit still long enough to eat are the causes of eating difficulties. Feelings of guilt do not precipitate eating difficulties in clients with the diagnosis of bipolar disorder, manic episode. Clients in a manic episode of bipolar disorder have a need to avoid and therefore control anxiety associated with depression; they do not have a need to control others. Clients in a manic episode of bipolar disorder have a need to avoid and therefore control anxiety associated with depression; they do not have a desire for punishment.

When a nurse is caring for a client with a major depressive disorder, the priority intervention should be helping the client:

Feel comfortable with the nurse. Before therapy can be started, a trusting relationship must be developed. A client with major depression does not have the impetus or energy to investigate new leisure activities. Participating in small-group activities is not appropriate initially; a trusting one-on-one relationship must be developed first. Initiating conversations about feelings will not be successful unless the client has developed a trusting, comfortable relationship with the nurse.

A client who was involved in a near-fatal automobile collision arrives at the mental health clinic with complaints of insomnia, anxiety, and flashbacks. The nurse determines that the client is experiencing symptoms of crisis. What is the nurse's initial intervention?

Focusing on the present Crisis intervention deals with the here and now; the past is not important except in building on client strengths. The client is anxious and uncomfortable because of the current situation; the focus is on the present, not the past. Psychotherapy is not appropriate for crisis intervention; psychotherapy focuses on the causes of current feelings and behavior and may be provided long term. Exploring the client's history of mental health problems is not significant to crisis intervention.

To further assess a client's suicidal potential, the nurse should be especially alert to the client's expression of:

Helplessness and hopelessness The expression of these feelings may indicate that this client is unable to continue the struggle of life. Anger and resentment are not indications of potential suicide; the client is still responding to the world, not attempting to leave it. Loneliness and anxiety are usually not sufficient to precipitate a suicide attempt. The client attempting suicide usually sees death as a release.

A female client and a nurse are standing next to each other in the mental health clinic when the client gets down on her hands and knees and says, "I'm a table." What is the best response by the nurse?

Hold out a hand to help her up while saying, "You're not a table; you're a person." The response "You're not a table; you're a person" simply states reality without attempting to argue the client out of the delusion; actual physical contact should be initiated by the client. The response "You were never a table before; you aren't a table now" denies the client's feelings and directly attacks the delusion, forcing the client to defend it. The response "You're safe here in the clinic; you don't need to be a table" is false reassurance; the client does not feel safe, and saying this does not make it so. Touching the client's arm could be frightening and overwhelming.

A nurse is planning an educational program for family members of clients with bipolar disorder. What clinical manifestations indicating the beginning of an episode of mania should the nurse include? Select all that apply.

Insomnia Irritability Financial irresponsibility During a manic episode there is a decreased need for sleep and clients do not feel tired. During a manic episode the primary mood is irritability; the emotions often fluctuate between euphoria and anger. During a manic episode there is a decrease in appetite. The client's increased activity and inability to sit still interfere with the ability to eat and drink. Hypersexuality, rather than decreased libido, is common during a manic episode. During a manic episode impulsivity, impaired judgment, and involvement in pleasurable activities may result in spending sprees that can have negative consequences.

A client whose depression is beginning to lift remains aloof from the other clients on the mental health unit. How can a nurse help the client participate in an activity?

Invite another client to take part in a joint activity with the nurse and the client. Bringing another client into a set situation is the most therapeutic, least threatening approach. At this point in time it is not therapeutic to allow the client to follow solitary pursuits; it will promote isolation. Explanations will not necessarily change behavior. Asking the health care provider to speak to the client about participating transfers the nurse's responsibility to the health care provider.

A client whose wife recently died appears extremely depressed. The client says, "What's the use in talking? I'd rather be dead. I can't go on without my wife." What is the best response by the nurse?

"Are you thinking about killing yourself?" The response "Are you thinking about killing yourself?" is the most important assessment to make because suicide is a possibility with every depressed client. The client has already said that he would rather be dead, and the response addresses only part of the client's statement. The response "What does death mean to you?" is a philosophical approach that will not encourage discussion of feelings. The client is probably unable to explain why he feels the way he does.

A depressed client tells the nurse, "I don't get out of bed most mornings because I don't feel like it." What is the best reply by the nurse?

"Getting up and involved in an activity should help lift your mood." Increased activity improves mood in depressed individuals. Although insomnia can be a problem in depression, this client is expressing an issue related to mood. "Most people don't like getting out of bed in the morning" discounts the client's feelings. Staying in bed will not improve the client's mood. The client does not have the psychic energy to relax and prepare for the day.

As the nurse considers a client's placement on the continuum of anxiety, a key in determining the degree of anxiety being experienced is the client's:

Perceptual field Perceptual fields are a key indicator of anxiety level because the perceptual fields narrow as anxiety increases. Memory state, creativity level, and delusional system are not related directly to anxiety level.

The nurse finds a disturbed, acting-out male client in the fetal position. What is the most appropriate intervention for the nurse?

Sitting down beside him and saying, "I'm here to spend time with you." Sitting down beside him and saying, "I'm here to spend time with you" shows acceptance of the client at his current level and allows the client to set the pace of the relationship. Tapping him gently on the shoulder to get his attention and then staying with him could be misinterpreted by any client and could precipitate an aggressive response. Going to him and saying, "I'll be waiting for you by the chairs, so please get up and join me" asks the client to reach out to the nurse; in the therapeutic relationship the nurse must reach out to the client. Even if the client is too withdrawn to respond, the nurse's physical presence can be reassuring, so leaving him alone is not therapeutic.

A teenager with anorexia nervosa is admitted to the adolescent unit of a mental health facility and signs a contract calling for her to gain weight or lose privileges. There is no weight gain after a week. What should the nurse explain to the client?

The prearranged consequences will go into effect. The imposition of the prearranged consequences reinforces the agreed-upon contract; a behavior modification program must follow through consistently on issues of cause and effect. Death from starvation is not therapeutic; it is threatening. Goals are not changed; prearranged consequences are instituted when goals are not met. Working with food will not stimulate the client's eating; this is not therapeutic or productive.

A client was recently given a diagnosis of a manic episode of a bipolar I disorder. What activity is most therapeutic for this client at this time?

Walking around the unit with a nurse Walking allows the client to burn excess energy in a safe, acceptable activity. A one-on-one activity demonstrates that the nurse cares and may allow the nurse to verbally interact with the client. A quiet activity such as a craft project for a person who is hyperactive is unrealistic and would be frustrating for the client. A game of table tennis would be too stimulating and competitive, both of which may increase anxiety. A hyperactive client does not have the ability to be quiet and focus on a card game.

A female client with a diagnosis of obsessive-compulsive personality disorder goes to the mental health center. She is restless, irritable, and angry at her adolescent children because they do not perform the household chores correctly and she has to do all the work again. What is the most therapeutic response by the nurse?

"It must be frustrating. How can you help them learn to do the chores correctly?" Noting that it must be frustrating and asking how she can help them learn to do the chores correctly validates the client's feelings and attempts to help the client problem-solve. The client may or may not be exhausted, and telling her so and suggesting that she take some time off from work to rest gives advice, which should be avoided because it promotes dependency. Telling her not to get so excited and asking why she feels that she has to do everything herself is judgmental and belittles the client. Although noting that the client is upset and asking whether she really thinks that her children are not typical teenagers attempts to validate the client's feelings, it also belittles the client because it implies that the children's behavior is acceptable and the client is being unreasonable.

A client with a history of alcohol abuse says to the nurse, "Drinking is a way out of my depression." Which strategy will probably be most effective for the client at this time?

A self-help group Members of self-help groups, particularly Alcoholics Anonymous, are living with the problem themselves; therefore problem identification and self-responsibility are emphasized and manipulation is limited. Long-term therapy tends to increase anxiety until resolution occurs; level of commitment and duration of therapy render it a less desirable choice for substance abusers. Depending on the client's feelings about religion, talking with a religious advisor may or may not be helpful. Whether talking with an alcoholic friend will be useful depends on the friend's drinking status; it may be helpful or harmful. These variables negate the effectiveness of this choice.

A psychologist has been a client on a mental health unit for 3 days. The client has questioned the authority of the treatment team, advised other clients that their treatment plans are wrong, and been disruptive in group therapy. What is the most appropriate nursing intervention?

Accepting that the client is unable to control this behavior and setting appropriate limits Clients who are out of control need to have limits set for them. The staff must understand that the client is not deliberately trying to disrupt the unit. Telling the other clients to disregard what the client is saying is demeaning the client in the eyes of the other clients and does not address the problem directly. Ignoring the client will not stop the disruptive behavior; also, the nurse has a responsibility to the other clients. Restricting the client's contact with other clients until the disruptive behavior ceases may be done as a last resort, but this approach should not be used until other alternatives have been explored.

What is the term used to identify the display of anger in a socially inappropriate manner?

Aggression While experiencing and demonstrating anger is a normal human reaction, when that anger is displayed in behaviors that are socially and emotionally unacceptable the behavior is termed aggressive. Defensiveness is a term that denotes the protection of oneself against real or perceived danger. Abuse is a general term that infers mistreatment of another individual that can be physical, sexual, emotional, or verbal. Battery is used to identify the carrying out of a verbal threat in a physical manner.

A nurse decides to use the CAGE screening questionnaire with a client admitted for substance abuse. What is the client abusing?

Alcohol The CAGE questionnaire is one of the simplest and most reliable screening tools for alcohol abuse. CAGE is an acronym for the key words (Cut down, Annoyed, Guilty, and Eye-opener) in the four questions asked of people suspected of abusing alcohol. The CAGE questionnaire is not designed to screen clients for barbiturate, hallucinogen, or multiple drug abuse.

A newly admitted client with an obsessive-compulsive personality disorder frequently performs a handwashing ritual. When attempts are made to set limits on the frequency or length of the ritual, the client's anxiety escalates and the client becomes verbally aggressive. What is most important for the nurse to do when the client performs the ritual?

Allow the client sufficient time to carry out the ritual. Rituals provide a means for the individual to control anxiety. If not permitted to carry out the ritual, the client will probably experience unbearable anxiety. The client has exhibited verbally aggressive behavior in the past, and this behavior may escalate. Safety of the client and others becomes an issue. The client probably already understands that the ritual is useless but is unable to stop the activity. These clients have no idea of what the ritual means, only that they must continue the ritual. Interrupting the ritual will have the effect of increasing anxiety, possibly to a panic level.

A client who was in an automobile accident is admitted to the hospital with multiple injuries. Approximately 14 hours after admission, the client begins to experience signs and symptoms of withdrawal from alcohol. Which signs and symptoms should the nurse connect to alcohol withdrawal? Select all that apply.

Anxiety Diaphoresis Psychomotor agitation When a person is withdrawing from alcohol, associated autonomic hyperactivity causes an increased heart rate and diaphoresis. The withdrawal of alcohol affects the central nervous system resulting in excited motor activity. Fatigue is associated with withdrawal from caffeine or stimulants. Anxiety is commonly associated with withdrawal from alcohol. A runny nose and tearing of the eyes are associated with withdrawal from opioids.

An 8-year-old child is found to have oppositional defiant disorder. What behavior noted by the nurse supports this diagnosis?

Argues with adults Oppositional defiant disorder is a repeated pattern of negativistic, disobedient, hostile, defiant behavior toward authority figures, usually exhibited before 8 years of age. Easy distraction, associated with attention deficit-hyperactivity disorder, reflects an inability to sustain focus on a task. Lying to obtain favors is associated with conduct disorder and reflects a violation of a societal norm. Initiating physical fights, violating the rights of others, is associated with conduct disorder.

A male client claims that the voices he hears are clearly telling him what actions and decisions to make. What is the nurse's most therapeutic response initially?

Asking the client the specifics of what the voices are telling him The nurse must first learn the content of the command hallucinations as a means of identifying the possibility of violence. Playing soft music after hallucinations have started is not a sufficiently strong stimulus to compete for the client's attention. Talking to the client when he is hearing the voices is too late; competing stimuli must be present to block the occurrence of hallucinations. The client cannot be talked out of a hallucination.

What is the nurse's ultimate goal when managing the care of a client diagnosed with generalized anxiety disorder (GAD)?

Assisting the client with the development of healthy, adaptive coping mechanisms GAD is characterized by the maladaptive use of worrying as a coping mechanism. The ultimate goal is for the nurse to help the client replace the ineffective worrying with effective, healthy coping mechanisms. It is not possible or even desirable to create an anxiety free environment; the goal is to help the client learn to deal with anxiety in a healthy manner. While identifying triggers is an appropriate goal, it is not the ultimate/definite goal for this diagnosis. It is not appropriate to eliminate all of the client's anxiety issues, because all individuals experience anxiety.

When selecting a room for a client with the diagnosis of bipolar I disorder who is hyperactive and talking nonstop in a loud, demanding voice, the nurse determines that the most important factor is for the:

Atmosphere be quiet and restful During the manic phase of the illness, the client responds to everything in the environment; therefore it is important that the room be quiet and restful to decrease stimulation. A room with a pleasant view is not an important consideration at this time for this client. A room close to the nurse's desk is too stimulating because of its location. Roommates with similar diagnoses and behaviors will probably increase both the client's and the roommate's behavioral acting out.

A client with an inoperable temporal lobe tumor is experiencing frightening audio hallucinations, especially when alone. How can the nurse best help the client cope with these hallucinations?

By suggesting that the client turn on the radio or television when alone Stimuli such as a television or radio encourage the client to remain reality oriented; research has shown that competing stimuli are useful in controlling hallucinations. Moving the client to a four-bed room closer to the nurses' station does not ensure that the client's needs will be met. Working out a schedule for visitors so the client will never be alone or having family or friends remain with the client until hallucinations stop is not realistic and fosters greater dependency; both solutions are focused on the client's inability to cope with the problem and will increase the client's fear of being alone.

A client is admitted to the acute psychiatric unit of the local community hospital. The client is guarded and suspicious. After a thorough evaluation, a diagnosis of schizophrenia, paranoid type, is made. What initial approach should be used by the nurse assigned to establish a therapeutic one-to-one relationship with this client?

Casual and honest Individuals with schizophrenia of the paranoid type are more apt to trust nurses who display matter-of-fact, predictable behaviors. The warm and friendly approach is too threatening to the individual with schizophrenia of the paranoid type, who does not trust others. The permissive and distant approach may be perceived as a lack of interest; these behaviors tend to reinforce a paranoid individual's social withdrawal. Watchful behavior on the part of the nurse reinforces a paranoid client's suspiciousness.

A nurse is caring for a client admitted to a mental health unit because of suicidal ideation. Which intervention provides the greatest safety for this client?

Constant one-to-one supervision A member of the health team provides a continuous presence to ensure the safety of a client who is at high risk for suicide. Although removing unsafe objects from the environment is important, clients who are intent on self-harm will find ways even if such objects are removed. Seclusion and four-point restraints are overly restrictive.

What nursing intervention is the priority in the period immediately after an emaciated 13-year-old child's admission to the hospital for starvation resulting from anorexia nervosa?

Correcting the child's fluid and electrolyte imbalances Anorexic children are usually severely malnourished and have severe fluid and electrolyte imbalances. Unless these imbalances are corrected, cardiac irregularities and death may occur. Rest and nutrition, information on diet and exercise, and assessment of physical and mental status are important, but none is the priority at this time.

Addicted clients commonly expect discrimination and lack of empathy from others. How can the nurse best overcome these expectations?

Demonstrating a nonjudgmental attitude

A client is using ritualistic behaviors. Why should a nurse give the client ample time in which to perform the ritual?

Denial of this activity may precipitate a panic level of anxiety. The repeated act protects the client against severe anxiety; interruption of the ritual will result in increased anxiety. The performance of a ritual is not anger turned inward on the self; the ritual reduces anxiety. Rituals are not activities that enhance self-esteem; they control anxiety. Pointing out that the behavior is inappropriate will further increase anxiety. The client does not want to perform the ritual but feels compelled to do so to keep anxiety at a controllable level.

A male client in a mental health facility turns his head to the side during a unit meeting as if he hears something. When the nurse comments about it, the client replies, "You know, it's that microcomputer those foreign agents implanted in my ear." In light of this statement, the nurse determines that the client is experiencing:

Delusional thoughts The client's statement reveals the cognitive disturbance called a delusion, which is a fixed set of false beliefs that cannot be corrected by reason. An illusion is a misperception of an actual environmental stimulus. A hallucination is a sensory experience, unrelated to external stimuli. Neologisms are made-up words understood only by the speaker.

A 20-year-old carpenter falls from a roof and sustains fractures of the right femur and left tibia. The client reveals a history of substance abuse. What is the primary consideration for the nurse who is caring for this client?

Determining the amount and time of last use of the substance Determining the amount and last use of the substance is the priority. Nurses should base their treatment of withdrawal symptoms based on the time and amount of last use. Confronting the client is not the nurse's responsibility at this time. The client must be helped to recognize that a problem with drugs exists. Because of cross-tolerance the client may need larger doses of analgesia for pain relief than a nonabuser would.

What therapeutic nursing intervention may redirect a hyperactive, manic client?

Encouraging the client to tear pictures out of magazines for a scrapbook Physical activity will help the client expend some of the excess energy without requiring him to make decisions or forcing other clients to deal with the behavior. The client's extreme activity limits his capacity for concentration or task completion. The client may disrupt the unit because of the excess activity and bossiness associated with this disorder. The client needs guidance and is not able to guide others.

A client with a personality disorder is playing cards with another person in the lounge. When the other person cheats at cards, the client responds by aggressively scattering the cards around the room. The nurse concludes that the client has:

Inadequate impulse control The client is angry and reacts impulsively; the action is unplanned and is not under the client's control. No data are provided to suggest that the client is out of contact with reality; the client is reacting to a real situation with anger. There is no identifiable cluster of behaviors to suggest that the client has a violent personality. There is no pattern of behavior to suggest an antisocial personality, which may or may not involve impulse control.

A female client with the diagnosis of obsessive-compulsive disorder attends a day treatment program. The client feels that her hands are dirty and has a need to wash them 70 to 80 times a day, and, as a result, her client's hands are red and raw, with some bleeding. An immediate nursing intervention for this client is to get the client to:

Limit the number of times she washes her hands. Reducing but not eliminating the handwashing still permits the client to cope with feelings of anxiety while aiming to reduce skin damage. The anxiety is too great for the client to understand why handwashing is not necessary. Recognition must precede the development of insight; neither can be done until the level of anxiety is reduced. Telling the client that she may not wash her hands will not allow the client any outlet for coping with extreme anxiety, which is the priority need at this time. Also, the client must wash her hands sometimes—for instance, after toileting.

When intimate partner violence (IPV) is suspected, the nurse plays an important role as an advocate for the victim. The advocate role includes several important components. Select all that apply.

Planning for future safety Validating the experiences Promoting access to community services Planning for the client's future safety needs, validating the client's experiences by letting the victim know that he or she is not alone, and promoting access to community services are all important roles of the nurse advocate. An advocate would not normalize the victimization by seeing the abuse as normal in the victim's relationship and failing to respond to the disclosure of the abuse.

A client in the psychiatric hospital is attempting to communicate by stating, "Sky, flower, angry, green, opposite, blanket." The nurse recognizes this type of communication as:

Word salad Word salad is an incoherent mixture of words. Echolalia is a pathologic repetition of another's words or phrases. Confabulation is the unconscious filling in of memory gaps with imagined or untrue experiences. Flight of ideas is a speech pattern of rapid transition from topic to topic. The client's statement is too limited to be considered flight of ideas.