Module 4 Exam

A schizophrenic client says to the nurse, "I keep getting these thoughts and hearing voices. They worry and consume me so that I can't always stop myself like my doctor told me to." Which intervention would the nurse suggest as a distraction technique?

"Have you tried to count back from 100 or listen to music?" Rationale: Distracting ways of coping with voices include reading aloud, describing an object in detail, listening to music, and watching television. Having the client try to count back from 100 or listen to music will assist in distraction. In the remaining options, the nurse suggests interacting techniques that reinforce the client's belief that the voices are real.

A client says to the nurse, "I'm worried about my husband. He's talking about ending it all since his law practice dropped off and his son by his late first wife died of a drug overdose — but he's too intelligent to hurt himself, isn't he?" Which response by the nurse is appropriate?

"Your husband is displaying behaviors that indicate a risk for self-harm." Rationale: Risk factors for suicide include male gender, professional status (physician, attorney, dentist, military personnel), loss to death, financial problems, and physical illness. Other risk indicators include a suicide plan, depressed mood, and prior attempts at suicide. In stating, "Yes, he's too intelligent to end it all," the nurse provides false reassurance. In responding, "I'm not sure. I don't know him that well," the nurse may be accurate, but the answer avoids the client's concern. The statement "Most people who talk about ending it all are just looking for attention." is inaccurate. Any implication of suicide should be taken seriously.

Which of the following clients is at the highest risk for suicide?

A 75-year-old woman with severe depression and crippling arthritis Rationale: An individual with a terminal or crippling illness is at high risk for suicide. Other high-risk groups include adolescents, drug abusers, individuals who have experienced social problems or recent losses or have little or no social support, and individuals with a history of suicide attempts and a suicide plan.

A home care nurse makes a visit to a client with a diagnosis of depression. The nurse finds the client unconscious on the floor, with an empty bottle of a prescribed tricyclic antidepressant lying near the client. What action must the nurse take immediately? A Inducing vomiting B Calling an ambulance C Administering syrup of ipecac D Counting the pills remaining in the bottle

B Calling an ambulance Rationale: An overdose of a tricyclic antidepressant can be fatal, regardless of the amount ingested. Serious life-threatening symptoms may develop after an overdose. Immediate emergency medical attention and cardiac monitoring are needed in the event of an overdose of a tricyclic antidepressant. The nurse would not induce vomiting or administer anything by way of the oral route if the client is unconscious. Counting the remaining pills provides no useful information and delays necessary and immediate intervention. Additionally, the question notes that the bottle of pills is empty.

Which statement made by a client with anorexia nervosa would indicate to the nurse that treatment has been effective?

D "I went out to lunch today with my cousin." Rationale: Anorexia nervosa is usually seen in adolescent girls who try to establish identity and control through self-imposed starvation. "I no longer have to lose weight," "I won't starve myself anymore," or "I'll eat until I don't feel hungry," are all verbalizations of the client's intentions. The statement "I went out to lunch today with my cousin" identifies a concrete action that can be verified.

A nurse sees a nursing assistant talking in an unusually loud voice to a client with delirium. Which action should the nurse take?

Determining that the client is safe, calmly asking the nursing assistant to join you outside the room, and informing the nursing assistant of the observation Rationale: The nurse must determine that the client is safe and then discuss the matter with the nursing assistant in an area out of hearing of the client. If the client heard the conversation, he might become more confused or agitated. Informing the client that everything is all right is inappropriate and a communication block. Speaking to the nursing assistant immediately to solve the problem, while in the client's room, could add to the client's confusion and embarrass the nursing assistant. Explaining to the nursing assistant that yelling in the client's room is tolerated only if the client is talking loudly could also add to the client's confusion.

A nurse is providing information to a group of nursing staff members about caring for suicidal clients. The nurse tells the group that:

Discussing suicide with a client is not harmful Rationale: An open discussion of suicide is not harmful, will not encourage a client to make the decision to commit suicide, and will, in fact, often help prevent it. Such a discussion gives healthcare personnel the opportunity to assess the likelihood of a suicide attempt by the client and take the necessary precautions to keep the client safe. The remaining options present incorrect information.

The nurse is preparing a care plan for a client with obsessive-compulsive disorder (OCD). Which should be the nurse's primary focus? Group therapy Recreational therapy Goals and objectives The client's medical diagnosis

Goals and objectives

A nurse is working with an older client who has been hospitalized and the client's family to formulate a plan for discharge. In guiding the discussion with the client and family, the nurse understands that most older persons prefer to live:

Independently but close to their children Rationale: Most older people prefer to maintain their independence while having the resource of children or family nearby to help in times of need. In general terms, the other options are not as favorably received by elderly people, but their reception also depends on the specific client and the specific situation.

A nurse is preparing a plan of care for an older client with a diagnosis of depression. In preparing the plan, the nurse recalls that:

Indications of dementia may be present in an older client with depression Rationale: Signs of dementia may be noted in an older client with depression. Often the older client is aware of the changes in mentation, leading to depression. The other options are all inaccurate statements.

A client with the diagnosis of schizophrenia is unable to speak, although nothing is wrong with the organs of communication. The nurse plans care knowing that this condition is referred to as:

Mutism Rationale: Mutism is absence of verbal speech. The client does not communicate verbally, despite intact physical structural ability to speak. Verbigeration is the purposeless repetition of words or phrases. Pressured speech refers to rapidity of speech, reflecting the client's racing thoughts. Poverty of speech means diminished amounts of speech or monotonic replies.

A woman is brought to the emergency department after an assault. She presents with complaints of dizziness, dyspnea, visual disturbance, and motor tension with hyperactivity. Which level of anxiety does the nurse recognize in the client's presentation?

Severe Rationale: A client who has severe anxiety complains of dizziness, dyspnea, and visual disturbances, and exhibits motor tension with hyperactivity. A client with mild anxiety is alert and attentive. A client with moderate anxiety experiences a sense of helplessness, apprehension, irritability, and vigilance. A client in panic experiences chest pain and a feeling of impending doom or death.

A client brought to the emergency department by the police after being mugged is extremely agitated, trembling and hyperventilating. What is the appropriate initial nursing action?

Staying with the client Rationale: This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is critical for the nurse to remain with the client. Processing the anxiety (e.g., asking questions) at this point will further increase the client's anxiety. The client in a severe state of anxiety is not able to learn relaxation techniques.

A nurse working with a victim of rape in a clinic setting is developing a plan of care for the client. Which short-term initial goal is most appropriate? .

The client will verbalize her feelings about the event. Rationale: A good initial short-term goal is verbalization of feelings about the event by the client. It is the nurse's responsibility to treat the client's physical wounds and provide information to her about the treatment plan. Resolution of feelings of fear and anxiety is a long-term goal.

A nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. Which priority instruction does the nurse include in the discharge plan?

The locations of shelters Rationale: Tertiary prevention of family violence includes assisting the victim once abuse has already occurred. The nurse should provide the client with information on where to turn for help. This includes a specific plan for removing oneself from the abuser and information on escaping, hotlines, and the locations of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for a client dealing with a violent person. Explaining the importance of leaving the violent situation does not provide the client with ways to seek assistance and shelter.

A nurse in the emergency department is helping care for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and, at times, physically immobile. The nurse interprets these behaviors as:

common/normal reactions to a devastating event Rationale: The symptoms noted in the question indicate a normal reaction to an intensely difficult crisis event. Although the client's initial reactions may be predictive of later problems, they do not constitute an abnormal initial response (e.g., depression, need for hospital admission, high suicide risk).

A client says to the nurse, "I'm really phobic about flying, so my husband and I always drove or took the train everywhere. Now he's been offered a big job in Europe, and if I don't get over this and fly with him, he says we're done. I'll be left to bring up our three children by myself." Which statement by the nurse would be therapeutic?

"I can teach you strategies to help master your panic. An antianxiety medicine would also help you." Rationale: A phobia is a persistent, irrational fear of a specific object, activity, or situation that leads to a desire for avoidance or actual avoidance of the object, activity, or situation. The nurse can teach strategies, such as relaxation training and thought-stopping, to help the client master her anxiety. There are also medications that the psychiatrist can prescribe to help ease the client's phobia. In stating, "No problem. You can be hypnotized to sleep through your trip," the nurse provides false reassurance and belittles the client's worries and fears. In responding, "I'm interested that it took his threat of leaving you to motivate you to seek help," the nurse uses a nontherapeutic change of subject that can only increase the client's anxiety and fear. This response also lowers the client's trust in her relationship with the nurse. In stating, "You seem more anxious and afraid of raising three children alone than of flying," the nurse changes the subject.

A postpartum client says to the nurse, "Sometimes I hear voices telling me to kill my baby to save her all the heartache I've been through." Which statement by the nurse would be most therapeutic?

"It is so good that you shared your feelings and thoughts with me. I'm going to help you get immediate attention for your voices." Rationale: The client is experiencing serious postpartum psychosis and command hallucinations. They require immediate medical attention and intervention for the protection of both the mother and her baby. In stating, "The voices will disappear in a few weeks as your hormones stabilize," the nurse disregards serious clinical manifestations. In responding, "This must be very distressing to you. Can you tell me more about the voices?" the nurse is trying to obtain additional data, but the client's statement indicates a psychiatric emergency that requires immediate intervention. In stating, "You will want to tell the doctor about them when you visit him next week. He is very interested in these voices and will want to help you with them," the nurse delays and refers the client to a psychiatrist 1 week from now, an intervention that may be too late for the mother and baby.

A client in skeletal traction says to the nurse, "I can't get any help with my care! I call and call, but the nurses never answer my light. Last night one of them told me she had other patients besides me! I'm very sick, but the nurses don't care!" Which response by the nurse would be therapeutic?

"It's hard to be in bed and have to ask for help. You call for a nurse who never seems to come?" Rationale: In the correct option, the nurse displays empathy while sharing perceptions. Sharing perceptions allows the client to validate the nurse's understanding of what the client is feeling and thinking. It opens the door for the client to share concerns, fears, and anxieties. In stating, "You poor thing! I'm so sorry this happened to you. That nurse should be reported!" the nurse is sympathetic but inappropriate regarding the negative comment about another nurse. In stating, "I think you're being very impatient. The nurses work very hard and come as quickly as they can," the nurse is assertive and defending the nursing staff. In stating, "I can hear your anger. That nurse had no right to speak to you that way. I will report her to the director. It won't happen again," the nurse expresses the client's frustration by labeling the client's feelings as angry and expresses disapproval of the nursing staff.

A client says to the nurse, "It's over for me — the whole thing is over." Which response by the nurse would be therapeutic?

"Let's talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members." Rationale: The therapeutic response seeks clarification, employs paraphrasing, and informs the client that the nurse needs to share any information that requires crisis intervention with other staff members. Asking, "What do you mean, 'The whole thing is over'?" employs paraphrasing, but the message is blunt and closed-ended. In stating, "Over? Well, that sounds pretty drastic to me. Let's discuss this in the strictest confidence," the nurse uses hysterical exaggeration (at an inappropriate time) and gives incorrect information regarding confidentiality. In stating, "Can you tell me more about why it's over for you? I'll keep your thoughts strictly confidential," the nurse uses the therapeutic technique of seeking clarification but does not clarify with the client that the information might need to be shared.

An alcoholic client says to the nurse, "I'm taking milk thistle, so I can drink all I want and never get cirrhosis." Which statement by the nurse would be therapeutic?

"Milk thistle is an herbal extract. It does seem to prevent liver damage and stimulate liver cell regeneration, but it can't prevent damage to other organs, like your brain." Rationale: The therapeutic nursing statement is the one that educates the client and also debunks the myth, held by the client, that taking milk thistle excuses drinking. In stating, "Milk thistle aside, you still need to stop using alcohol. You have a severe drinking problem," the nurse denies the benefits of milk thistle (Silybum marianum) by avoidance and preaches to the client about alcoholism, which is nontherapeutic when the client is in denial. In asking, "If milk thistle is so effective, I wonder why the liquor industry isn't lobbying to put it in alcohol?" the nurse uses sarcasm and absurdity, both of which are nontherapeutic. In stating, "Milk thistle is used in Europe this way, but research findings are limited, so I'd stop drinking if I had a problem like you do," the nurse uses sarcasm.

A nurse employed in a home care agency is assigned a recently widowed client. When the nurse arrives at the client's home, the ordinarily immaculate house is in chaos, and the client is disheveled, with the odor of alcohol on his breath. Which statement by the nurse would be therapeutic?

"You seem to be having a very difficult time

A client who has twice attempted suicide says, "If people would just leave me alone and let me do what I want with my life, I could get on with what I want to do." Which response should the nurse should give to the client?

"You've tried to end your life twice, yet you feel that everyone should let you do what you want to do?" Rationale: The therapeutic response is the one that offers reflection, which permits the client to observe the content of what she is saying. In stating, "Of course, you can't be left alone to get on with what you want to do," the nurse makes a response that is social and belittles the client's feelings. In stating, "Okay, go ahead and do whatever you want to do. Human beings have free will," the nurse makes a response that seems sarcastic and angry; it is also judgmental and biased. In stating, "Sounds like you're angry with people for caring enough about you to try to keep you from hurting yourself," the nurse makes a premature judgment.

Family members awaiting the outcome of a suicide attempt are tearful. Which response by the nurse would be most therapeutic to the family at this time?

A "I can see that you are worried." Rationale: The correct response involves the use of the therapeutic technique of clarifying. In stating, "You have nothing worry about," the nurse provides false reassurance. In stating, "You can see your loved one soon," the nurse focuses on an important issue at an inappropriate time (family members are tearful). In stating, "Everything possible is being done," the nurse uses clichés and false reassurance.

A client has just been admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. The nurse observes the client for compulsive behavior involving repetitive:

Actions Rationale: A compulsion is a repetitive act, whereas an obsession is a repetitive thought. A phobia is a repetitive fear, and delusions are characteristic of schizophrenia.

A client with schizophrenia and his parents are meeting with the nurse. One of the young man's parents says to the nurse, "We were stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he's had another relapse, and we can't understand why he stopped his medication." Which response by the nurse is appropriate?

Asking the client, "How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?

A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem worth it anymore. Why shouldn't I just end it all?" Which of the following statements should the nurse use to gather additional data from the client?

B "Tell me what you mean by that." Rationale: The correct statement allows the client to tell the nurse more about what the current thoughts are, a therapeutic communication technique. The incorrect options are statements that change the subject and block communication.

A client says to the nurse, "I don't do anything right. I'm such a loser." What is the appropriate response?

B "You don't do anything right?" Rationale: The correct response allows the client to verbalize his feelings. With this response, the nurse can learn more about what the client really means. This option also repeats the client's statement and allows the lines of communication to stay open. The incorrect options are closed-ended statements that do not encourage the client to explore his feelings further.

A client who is undergoing psychiatric counseling calls a nurse on a hotline, crying, and states, "My priest assaulted me when I was an altar boy, and my dad just found out. He's got a gun, and he's driving over to the church rectory. I don't know what to do." Which response by the nurse is most appropriate initially?

C "Call the priest immediately and tell him to lock the doors until the police arrive. I'll call the police." Rationale: Usually the volunteers on hotlines are trained to keep the client on the line, but in this case, the duty to warn the priest of the danger he is facing is paramount. When violence erupts, the nurse must think and act quickly and with clarity. "How did your dad learn of your abuse by clergy?" is off focus and inappropriate to the situation. Telling the client, "Call the police immediately and then call the priest to warn him that your dad has a gun," is incorrect, because the priest should be warned first. In stating, "You will want to come in to see our psychiatrist with your father, but, for now, call the police and tell them what happened," the nurse does not focus on the imminent violence described in the question.

A client in halo traction says to the nurse, "I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is." Which response by the nurse is therapeutic?

C "Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up, before you move." Rationale: In the correct option, the nurse employs the therapeutic communication technique of reflection, then offers a problem-solving strategy that will help improve the client's peripheral vision. In stating, "No one ever gets used to that thing! It's horrible," the nurse provides a social response that contains emotionally charged language and could increase the client's anxiety. In stating, "If I were you, I'd have had the surgery rather than suffer like this," the nurse undermines the client's faith in the medical treatment being used by giving advice that is insensitive and unprofessional. In asking, "Why do you feel like this when you could have died of a broken neck? This is the way it will be for several months. You need to accept it, don't you think?" the nurse uses excessive questioning and gives advice, both of which are nontherapeutic.

A schizophrenic client says, "I'm away for the day ... but don't think we should play ... or do we have feet of clay?" Which alteration in the client's speech does the nurse document?

Clang association

A schizophrenic client in the psychiatric inpatient unit is yelling, "The CIA is trying to kill me. I know they're plotting to kill me so they can overthrow the government." On the basis of the client's statement, which clinical manifestation would the nurse document in the client record?

Evidence of persecutory delusions Rationale: A persecutory delusion is the false belief that one is being singled out for harm by others, generally in the form of a plot by other people against the client. Paranoia is an intense and strongly defended irrational suspicion. An idea of reference is the misconstruing of trivial events in order to give them personal significance. A somatic delusion is the false belief that the body is changing in an unusual way (e.g., rotting inside).

A nurse brings a meal tray to a psychotic client in his hospital room. The client refuses the meal and says, "I'm not eating any more poisoned food while I'm vacationing here. I'm starting on a fast to stay healthy and alive." Which nursing intervention would be most appropriate initially?

Having the client eat with other clients in the community dining room Rationale: Having the client eat with other clients in the community room decreases the amount of time in which the client can stay isolated and engage in suspicious thinking. Of the options provided, this would be the initial intervention. It does not guarantee that the client will eat but does reduce the client's isolation time. Taking the tray away and canceling all meals until further notice and eating some of the food off the client's tray to prove that it isn't poisoned are both incorrect because they support the client's delusional thinking. Telling the client that the psychiatrist will be called for a prescription for a tube feeding is incorrect because it is a premature action that would lead to a regressive struggle with the client and is also a threat to the client.

A nurse determines that a client whose son died in a car accident is at risk for self-harm. Which intervention is most appropriate initially?

Making a "no suicide" contract with the client Rationale: The nurse would first plan to implement a "no suicide" contract when a client is at risk for self-harm. The safety of the client is the priority. The nurse would encourage the client to express angry, hostile feelings, not suppress them. Providing a peaceful place for the client to meditate is incorrect because the nurse would not want the client to isolate himself. Rather, the nurse would promote social interaction for the client. The nurse would help the client express (not control expression of) feelings that are painful.

A nurse working in a mental health unit reads a client's medical record and notes documentation that the client has been experiencing flashbacks. The nurse interprets this as a classic sign of:

Post-traumatic stress disorder Rationale: Flashbacks are the classic manifestation of post-traumatic stress disorder, or PTSD, and are not associated with depression, obsessive-compulsive disorder, or schizophrenia.

Which of the following steps should be included in the care of a 13-year-old hospitalized child who has been abused?

Providing a caring environment that fosters the development of trust Rationale: The abused child usually requires long-term therapeutic support. The environment during the child's healing must be one in which trust and caring are provided for the child. Encouraging the child to avoid the abuser reinforces fear. Teaching the child to make intelligent choices when confronted with an abusive situation and having the child identify the abuser if that person should visit while the child is hospitalized are asking the child to behave with a maturity beyond that which would be expected for a 13-year-old.

The nurse is assigned to care for a client experiencing a crisis. What is the appropriate initial nursing intervention for this client? Providing authority and action Displaying an attitude of detachment and efficiency Providing hope and reassurance that the crisis is temporary Demonstrating confidence in the client's ability to deal with the crisis

Providing authority and action

A nurse is participating in a care planning conference for a client with obsessive-compulsive disorder (OCD). Which does the nurse expect to see as the focus of care?

Reducing the client's anxiety

A client is severely injured, sustaining a full-thickness circumferential burn to the left leg, after passing out as a result of drinking alcohol and falling into a fire while on a camping trip. In report, the nurse is told that the client has just signed consent for amputation of the limb and that the procedure is scheduled for tomorrow. While caring for the client, the nurse notes that the client is upset and withdrawn. What is the most appropriate nursing action at this time?

Reflecting back to the client that he appears upset Rationale: Reflection statements tend to elicit deeper awareness of feelings. In addition, reflecting to the client that he or she appears upset validates the perception that the client is upset. Letting the client have some time alone to grieve the impending loss of the limb is premature; the client needs support at this time. Informing the physician of the client's depression and requesting medication to assist the client in coping with the diagnosis is also an example of initiating an intervention prematurely. Reminding the client that the injury was a result of alcohol abuse and referring him for counseling is inappropriate and a block to communication.

A client is scheduled to undergo electroconvulsive therapy (ECT). Which client concern is of the highest priority? g

Risk for impaired breathing Rationale: NPO status for 6 to 8 hours before a procedure, removal of dentures during the procedure, and administration of medication as prescribed to diminish oral secretions are all safeguards against aspiration during ECT. Although fear and anxiety could also be concerns, they are not the most important ones. There is no reason to infer that distorted body image is a consideration.

A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on herself. The nurse plans to focus the initial assessment on:

The physical condition of the client Rationale: The initial priority in the nursing assessment of a client in a crisis state is to assess physical condition, potential for self-harm, and potential for harm to others. Once these questions have been answered and the appropriate interventions have been initiated, the nurse may proceed in providing psychosocial care.

A 30-year-old client says to the nurse, "I want to die. I think about it a lot, but I don't know how in the world to do it." On the basis of the client's statement, the nurse determines that:

The risk for suicide exists and continued assessment is needed Rationale: The words "I want to die" indicate a suicide risk warranting continued assessment. Any language indicating a desire for self-harm must be viewed as serious. This question presents no data indicating a history of self-harm. The other options are incorrect interpretations.

A nurse employed in a mental health unit is reviewing the work schedule. At what time does the nurse expect that additional client safety precautions will be provided?

Weekends Rationale: Because there is less availability of nursing staff on the weekends, risk to client safety increases, necessitating extra attention on the part of staff. There is often less availability of staff during shift changes as well. The nurse should increase precautions at these times. The night shift is also a high-risk time.

A schizophrenic client attending a support group held by a clinic nurse says to the nurse and the group, "I've been laid off from my job at the factory, and so have 300 other people, so I'll have to get a new job. For now, there's unemployment." Which statement by the nurse would be most therapeutic at this time?

"Have other people in the group been feeling the job crunch this week? When changes like this occur, it's best to increase the number of your appointments with me for a short time." Rationale: The nurse is leading a support group for schizophrenic clients, so it is important to address every group member when possible and not single out one member for special attention. The correct option is open-ended, encourages group sharing of experiences and support, and teaches the members about the need to increase visits whenever schedules change abruptly and create stressful situations. In stating, "It seems that the stock market is responsible for mass unemployment in our factory-based city," the nurse changes the focus from feelings and experiences to intellectualize, a nontherapeutic intervention. In responding, "I'm sorry to hear that you've lost your job. Why not make an appointment to come in and talk with me this week?" the nurse expresses sympathy rather than empathy and personalizes the invitation for an appointment that may cause jealousy among the other clients in the group. In asking, "How do people feel about this loss of employment? Does anyone in the group who experienced this have any advice?" the nurse asks a question of the group that is off focus.

A client who delivered a baby 4 months ago says, "I keep thinking that this boy is some sort of demon. All he does is cry. It's as if I can't feed him enough or satisfy him in any way. My daughter never gave me this kind of trouble. I really can't stand it." Which statement by the nurse is most important?

"Have you been having any thoughts of hurting your baby?" Rationale: The most important statement is the one in which the nurse assesses the client for her risk of harming the baby. This client may be experiencing postpartum depression, and the rumination over the baby could lead the mother to harm the baby. The statements in the incorrect options change the subject and close off expressions of concern by the client.

A psychiatric nurse is playing a card game with a client in the day room. The client states to the nurse, "The voice in my head is telling me that you're cheating." Which of the following responses by the nurse is therapeutic?

"I do not hear any voices. Has the voice said anything else?" Rationale: When caring for a client experiencing delusions or hallucinations, the nurse should listen to the client, present reality, and collect more data regarding the content of the delusion and/or hallucination. Stating, "I do not hear any voices. Has the voice said anything else?" is correct because it presents reality and collects more data from the client. Although stating, "Is the voice telling you to do anything?" collects more data, it does not present reality. Stating, "It isn't possible for people to hear voices in their head" and "I don't believe that you are hearing voices" are non-therapeutic and do not address the needs or feelings of the client.

A manic client who tends to be manipulative says angrily, "You had better let me out of here, or I'm going to call my lawyer. My boss has good friends with the owners of this tin-pot place you call a 'mind holism respite.'" Which statement by the nurse would be most therapeutic?

"I know that you feel that you're doing your very best right now, but you are yelling. Take some time out and some deep breaths, and I'll speak to you in half an hour." Rationale: Anger is an emotional response to the perception of frustration of desires, threat to one's needs (emotional or physical), or a challenge. It reflects rage, hostility, and the potential for physical or verbal destructiveness. With manipulative clients, solutions that provide options and empathy work best. An authoritarian style in which the nurse labels aggression is inappropriate and is not effective with such clients. Additionally, the remaining options may further anger the client and escalate the client's behavior.

The mother of a child who is taking methylphenidate hydrochloride (Ritalin) tells the school nurse that she is administering an over-the-counter (OTC) cough syrup to her son. Which response by the nurse would be appropriate?

"I think that you should stop giving this medicine to your son until I can check its content with the pharmacy." Rationale: When a client is taking methylphenidate hydrochloride (Ritalin), no OTC medications should be administered without the approval of the pharmacist or physician. Such medications could contain caffeine, which must be avoided. In stating, "Your son should never take any medicine, even if it's OTC," the nurse is lecturing and belittling. In stating, "His cough could be a side effect of the Ritalin" or "You may administer a small amount of OTC cough syrup without a problem, but not for more than 3 days," the nurse provides inaccurate information.

A nurse is monitoring a client who is in seclusion. The nurse determines that it is safe for the client to come out of seclusion when the client states:

"I'm no longer a threat to myself or others." Rationale: The client in seclusion must be assessed at regular intervals (usually every 15 to 30 minutes) for fulfillment of physical needs, safety, and comfort and should be released from seclusion as soon as possible, provided that safety has been ensured. The statement "I'm no longer a threat to myself or others" indicates that it may be safe to remove the client from seclusion. The statement "I need to go to the bathroom" indicates a physical need that could be met with a urinal or bedpan, if necessary. It does not indicate that the client has calmed down enough to leave the seclusion room. The statement "I want to be alone for a while in my own room" could be an attempt to manipulate the nurse. It gives no indication that the client will control him or herself when alone in his or her room. The statement "I can't breathe in here. The walls are closing in on me" indicates the need for supportive communication or possibly a prescribed medication. It does not necessitate the discontinuation of seclusion.

A schizophrenic client is seen seemingly talking to someone who isn't there. Which nursing statement would be most therapeutic initially?

"I've noticed your eyes darting back and forth, and I wondered whether you might be hearing voices." Rationale: The most therapeutic nursing statement is the one in which the nurse addresses the client's behavior and asks whether the client is hearing voices. With this statement, the nurse also assesses the client's behavior. If the client is hearing voices, the nurse prevents reinforcement of the hallucinatory thinking by telling the client that he or she does not hear them. In asking, "Today is my birthday. Would you like to go on an outing with my family?" the nurse nontherapeutically changes the focus from the client. In stating, "You need to wash up and get ready to go to supper in the cafeteria with the other clients now," the nurse ignores the client's obvious psychotic behavior and directs the client to socialize with others. Such an intervention is not usually positive, because it floods the client with stimuli that may contribute to an escalation of psychotic behavior. In asking, "You were telling me yesterday that your mother died last June of cancer. Can you tell me more about that?" the nurse uses distraction, summarization, and refocusing.

A nurse performing a lethality assessment asks the client whether he is thinking of suicide. Which statement by the client would be of most concern to the nurse?

"No, I wasn't, but I am now, thanks to you." Rationale: The client's response that he is now thinking about suicide is of the greatest concern to the nurse. In making the statement "I hadn't thought of that, but I can see that you are" the client projects his own thoughts of suicide onto the nurse. In stating, "Of course not, but there are days when I think that I should be," the client is being sarcastic but is not specifically talking about suicide. In stating, "What is suicide going to do for me except get me excommunicated from the church?" the client indicates that suicide is not an option because of his religious beliefs.

A nurse is caring for an older adult client who says, "I don't want to talk with you — you're only a nurse. I'll wait for my doctor." Which of the following responses by the nurse would be therapeutic?

"So you're saying that you want to talk to your physician?" Rationale: The nurse uses the therapeutic communication technique of reflection to redirect the client's feelings back for validation and focus on the client's desire to talk with the physician. The correct option involves the use of reflection. The nursing responses in the other options are nontherapeutic. Remember that the nurse places the client's well-being first and foremost during care.

An alcoholic client who has been admitted to the mental health unit states to the nurse, "The judge made me come in here. My blood alcohol level was only 0.20% when the cop pulled me over in my car." Which statement by the nurse is most appropriate?

"This level means that you consumed several drinks of alcohol and would be experiencing depressed motor function of the brain. You would have been staggering and clumsy and your judgment would have been impaired, but you seem to feel that the judge was unreasonable for sending you here." Rationale: In most states (although the blood alcohol level, or BAL—designated as the indicator of intoxication—does vary), the legal alcohol limit is 0.08%. The most appropriate response is the one that teaches the client about his blood alcohol level and directs him to focus on his action and behaviors. In asking, "Did you ask the judge to clarify his decision to make you come here?" the nurse seeks clarification from the client, which closes off the expression of feelings by changing the focus of the discussion. In stating, "This reading means that you had consumed enough alcohol to put you close to the legal intoxication level. You were lucky because you just missed that level," the nurse gives inaccurate information about the BAL. In responding, "Well, the legal limit is much less than that, so you avoided a drunken driving charge by coming here. Seems to me that the judge treated you pretty leniently by allowing you to take refuge here. Don't you agree?" the nurse gives opinions and is judgmental, then asks for agreement in a sarcastic style of communication.

A schizophrenic client exhibits confused and unintelligible speech. Which nursing statement would be most therapeutic?

"This morning you are participating in the tree-decorating ceremony for the unit." Rationale: The most therapeutic technique for assisting a client whose speech is confused and unintelligible is to emphasize what is happening in the here and now and involve the client in simple reality-based activities. "Got it. The 'blinks' are 'taking over' the 'bumpers'" is unintelligible speech on the part of the nurse and reinforces the client's behavior. In stating, "I can't understand what you're saying. You have to talk more clearly!" the nurse begins with an appropriate response, but demanding that the client speak more clearly is inappropriate. In responding, "I can't understand you. Are you asking me to stay with you while you eat supper?" the nurse is guessing at what the client has said.

A client in a retirement center rings the night alarm and says to the nurse, "Look at this old man! He keeps breaking into my apartment! You've got to get him to stay out of here so I can sleep." Which statement by the nurse would be most therapeutic?

"This must be very troubling to you, but I can't see the old man. Perhaps I could stay with you for an hour or so while you try to rest." Rationale: The most therapeutic nursing response is the one that expresses empathy and helps orient the client to reality. It also offers self, builds trust, and provides support for the client's distress. In asking, "Why not just throw him out yourself and lock up once and for all?" the nurse reinforces the hallucination and delusional thinking by responding as if the old man is really there. In stating, "Now, you know that you're always seeing things and people at night who aren't there," the nurse is patronizing and belittling in responding to the client's concerns, a nontherapeutic communication. In responding, "I'm sure that you're very frightened right now. Do you recall my telling you that this is called sundowner syndrome? Go to sleep and he'll leave your apartment," the nurse is lecturing the client and giving advice, which is not therapeutic.

A client says to the nurse, "I came in to see you because I've been off my medication for 4 years but I feel as though I may be getting depressed again. I've been despondent again and thinking I should have ended it. That's why I'm here to get help." Which response by the nurse would be therapeutic?

"Well, it's been more than 4 years, so you've done really well. Sounds like you're right about getting depressed again, though. Can you tell me what's been happening with you lately?" Rationale: The therapeutic response is the one in which the nurse validates the client's drug-free time. In addition, in the correct option the nurse validates the client's self-assessment and supports and offers positive reinforcement. Finally the nurse begins to assess the client completely and attempts to identify precipitants. By stating, "Well, you really have had a good long drug-free time, but it sounds as if the doctor needs to reorder your medication at once," the nurse is premature in determining that the medication needs to be restarted; a thorough assessment must be performed first. In stating, "If you've been able to be drug free all this time, you probably don't need to restart the medicine. You probably just need some therapy to help you manage stress," the nurse jumps to giving advice and offering suggestions without performing a complete assessment. In stating, "Well, it's similar to when a client gets battered — things have to boil over before the police can act — so you need to be suicidal to get admitted to a hospital or hurt yourself before the doctor can restart the medication," the nurse provides an incorrect statement and sarcastic information.

A 2-year-old child is a suspected victim of child abuse and the nurse is interviewing the child's parent. Which statement by the parent indicates the possibility of child abuse? "

"When I tell my child to do something, I don't expect to have to repeat myself." Rationale: One characteristic of abusive parents is too-high expectations. As a result, the child cannot live up to the expectation of the adult parent. Unrealistic expectations result in disappointment and frustration of the parent; the parent may even believe that the action of the child is intentional or done out of spite and may react in an excessive manner, resulting in severe injury to the child. Therefore the nurse would be concerned about child abuse if a parent were to state, "When I tell my child to do something, I don't expect to have to repeat myself." The statements in the other options are not characteristic of a child abuser.

A client says to the nurse, "I've ruined my life. I left college with only a few credits to go. I keep telling myself that I'm going to make it as a writer, but I'll be a loser and a nothing for the rest of my life." Which response by the nurse is therapeutic?

"You seem to be saying that your choices are final and that you've lost any other opportunities." Rationale: The client in this question is engaging in catastrophizing rather than reframing and viewing other alternatives. The task for the nurse is to assess the lethality of the client's situation and to help the client feel empowered to take another course of action and find the perseverance and confidence to do so. The therapeutic response here is the one that is nonjudgmental. In responding, "What are you saying? Sounds like you need to pull yourself together and go back to school," or "Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get," the nurse communicates with the client as a parent, using a judging style. In stating, "Having faith in yourself is one thing, but looking at your options realistically is another," the nurse communicates prematurely and gives advice.

A client who has expressed suicidal ideation in the past says to the nurse, while shuffling several documents in an effort to organize them, "Well, I'm feeling so much better now since I got organized. My lawyer wrote my will and durable power of attorney." Which response by the nurse is appropriate?

"You talk about getting organized. Are you thinking of killing yourself?" Rationale: The client is exhibiting behaviors that indicate plans for suicide. Talking of suddenly "feeling so much better" and putting affairs in order are key verbal and behavioral clues that the client is planning to commit suicide. In exclaiming, "Good grief! You don't look organized to me," the nurse nontherapeutically uses hysterical exaggeration, which minimizes the client's feelings. In asking, "Okay, what are you up to today? Your behavior is not appropriate," the nurse uses teasing to determine the client's behaviors, which minimizes them. Additionally, the nurse is employing a nontherapeutic technique of judging. In stating, "If you keep behaving like this, you know that I'll have to tell the doctor and we'll have to seclude you," the nurse uses a threat.

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this! I'm the one who's dying." Which response by the nurse would be most therapeutic?

"You're feeling angry that your family continues to hope for you to be cured." Rationale: Reflection is the therapeutic communication technique in which the client's feelings are restated to validate what the client is saying. The correct option involves the use of reflection. In asking, "Have you shared your feelings with your family?" the nurse attempts to assess the client's ability to openly discuss these feelings with family members, but this is not the most therapeutic response of the options provided. In stating, "Well, it sounds like you're being pretty pessimistic," the nurse makes a judgment and is nontherapeutic. In stating, "I think we should talk more about your anger with your family," the nurse attempts to use focusing, but the attempt is premature.

An adolescent client says, "I'm just a burden to my folks. They wish I'd never been born. My dad told me he had to marry Mom because she got pregnant." Which response by the nurse would be therapeutic?

"You're feeling that your folks didn't want you, but they chose to marry and have you." Rationale: In the correct option, the nurse uses reflection to explore the client's lethality risk and then uses reframing to determine whether the client is able to view what happened in a different way. In suggesting, "You feel that you were a burden and not wanted? Let's talk with your parents to see whether you're right," the nurse uses paraphrasing but is then nontherapeutic in trying to persuade the client to talk to the parents. In suggesting, "Let's speak with your parents about what you've just told me. Let's ask whether you were truly unwanted," the nurse uses a parental approach, which may be threatening to the client, who seems to have been unable to talk with the parents before now. In stating, "Sounds like your father was very inappropriate, but I'm certain that he didn't mean that you were a burden to him," the nurse offers an opinion about the client's father and then provides false reassurance.

A client with major depression says to the nurse, "I should have died. I've always been a failure." Which response by the nurse is therapeutic?

"You've been feeling like a failure for some time now?" Rationale: Addressing the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. The incorrect options are responses that block communication because they minimize the client's experience and do not facilitate exploration of the client's expressed feelings.

A student calls the campus crisis hotline and tells the nurse, "I went out to a sorority party last week and drank too much. Someone raped me, but when I told my folks about it, they acted like it was my fault. I feel so dirty and used." Which statement by the nurse would be most therapeutic?

"You've had an awful experience, but it's not your fault that it happened. Can you come in and talk to me about it in more detail?" Rationale: Rape is vaginal or anal penetration against the victim's will and consent. The student is in crisis and needs counseling. Her call seems to be the result of her being unable to turn to her parents as she might have been able to in the past. The nurse needs to let the student know that the rape was not her fault. Many students overdrink but are not raped just because they were inebriated. By asking, "Would you come in to talk with me in the strictest confidence?" the nurse assures confidentiality, but this option is nontherapeutic because a bridge of trust has not yet been established with the client. In responding, "I believe that you can feel a lot better about yourself. Won't you come in to see me tomorrow?" the nurse offers opinions on outcomes and delays treatment, which is nontherapeutic. In responding, "Parents always feel that their daughter could never be raped. I could talk to them for you, if you'll let me," the nurse lectures the student on why her parents are not supportive without ever having met them. This answer is nontherapeutic and insensitive.

An acutely ill schizophrenic client says to the nurse, "He keeps saying that he likes you, and I keep telling him you're married, but he won't listen, and I think he's going to get fresh with you." Once the nurse has determined that the client is hallucinating, which response to the client would be most appropriate statement?

A "Try not to listen to the voices right now so that I can talk with you." Rationale: The appropriate statement by the nurse is the one that does not acknowledge the client's hallucinations. By responding, "I think that you can help him stop his behavior if you concentrate" or "Tell him I said to mind his p's and q's or I'll call the police on him," the nurse acknowledges the hallucinations. The nurse attempts to interpret the client's thinking with a statement such as "I think that you're trying to share your own feelings toward me, but you're shy."

An adolescent client has graduated high school and is preparing to leave home to attend college. The adolescent is distressed about this life change. The nurse plans to implement crisis interventions, knowing that this situation is characteristic of:

A maturational crisis Rationale: A maturational crisis involves the normal life transitions that produce changes in individuals and how they perceive themselves, their roles, and their status. A situational crisis occurs when a specific external event disturbs an individual's psychological equilibrium. An adventitious crisis is an unpredictable tragedy that occurs without warning. An individual may experience crisis; however, there is no formal type of crisis known as "individual crisis."

A client tells the nurse, "I am a queen. I'm mean, and I gleam." The nurse recognizes this as an example of:

Clang associations Rationale: Clang associations often take the form of rhyming. Repetition of words or phrases that are similar in sound (rhyming) but in no other way is one of the patterns of altered thought and language noted in schizophrenia. Echolalia is an involuntary parrotlike repetition of words spoken by others. Tangential speech is characterized by a tendency to digress from an original topic of discussion in which a common word connects two unrelated thoughts. Loosened associations are a sign of disordered thought processes in which the person speaks with frequent changes of subject and the content is only obliquely related, if at all, to the subject matter.

A 24-year-old schizophrenic client says, "I was in college and suddenly I was hearing voices telling me I was no good and that I should jump off the bridge by our college. My parents came and got me when I called them. We thought that I had inadvertently taken drugs at a party or something. My psychiatrist says that if I can improve, I can return to college next semester." Which of the following guidelines does the nurse plan to incorporate into teaching of the client and family about self-care on the client's return to college?

Compliance with the treatment regimen, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living a balanced lifestyle Rationale: Self-care guidelines for the client include compliance with the treatment regimen, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living a balanced lifestyle. Telling all friends about the illness so that they can support the client's avoidance of alcohol and drugs and help the client maintain a balanced lifestyle is incorrect. Although the closest supportive friends need to know and understand the illness, not everybody does. Limiting college attendance to commuter status to maintain a supportive family group and avoiding drugs, alcohol, and the strain of socialization is incorrect. Not allowing the client to be independent and follow a normal growth and development pattern would retard the client's growth. Socializing with one supportive friend is incorrect because it is best to bring as many supportive persons to the client as possible.

A nurse is caring for a hospitalized client with an alcohol abuse disorder. In reviewing the client's discharge outcomes, the most positive outcome is that the client states that he or she will:

Continue to attend Alcoholics Anonymous meetings Rationale: All of the outcomes deserve support by the nurse, but the option, continue to attend Alcoholics Anonymous (AA) meetings, will help the client abstain from alcohol and provide the client with a support group. This is the most positive outcome.

A nurse is preparing a discharge plan for a client who has attempted suicide. The nurse understands that the plan of care should focus on:

Contracts and immediate available crisis resources Rationale: Crises may occur between appointments. Contracts help make clients feel responsible for keeping their promises, giving them a feeling of control. Encouraging the family to always be with the client is unrealistic. Follow-up appointments and providing phone numbers will not ensure immediate crisis intervention.

A schizophrenic client is admitted to the inpatient psychiatric unit. The client is exhibiting clang associations, word salad, and loose associations. Which problem does the nurse recognize that the client is experiencing?

Inability to communicate effectively Rationale: Clang associations, word salad, and loose associations are language disturbances that indicate a client's inability to communicate effectively. These manifestations are not associated with coping or sensory alterations.

A moderately depressed client who was admitted to the mental health unit 2 days ago suddenly begins smiling and reports that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by:

Increasing the level of suicide precautions Rationale: A client who is moderately depressed and has only been hospitalized for 2 days is very unlikely to have had such a dramatic cure. When a depressed mood suddenly lifts, it is very likely that the client has made the decision to harm him- or herself. It is at this time that the client has the energy to perform the act. Therefore suicide precautions are necessary to keep the client safe. The other interventions will not provide the necessary safety precautions.

A resident of a long-term care facility who has Alzheimer's disease becomes agitated when a group of children comes to sing and dance at the facility and tries to take one of the children to her room. Which of the following pieces of information should the nurse use when approaching the client about this behavior?

Individuals with Alzheimer's disease have difficulty tolerating excessive stimulation and changes in routine. Rationale: Clients with Alzheimer's disease, a form of dementia, are likely to be intolerant of excessive stimulation and changes in routine. The remaining options are incorrect statements about the client with Alzheimer's disease.

A nurse preparing to admit a client with obsessive-compulsive disorder (OCD) to the mental health unit observes the client for certain characteristic behaviors. What are they?

Inflexibility Rationale: Inflexible behavior is characteristic of the client with OCD. Clients are not usually hostile unless they are prevented from performing the obsession or compulsion, because that is what eases the anxiety. Extreme fear, hostility, and adaptability are not characteristics of OCD.

A nurse has been closely observing a client who has been displaying aggressive behaviors and notes that the client's aggressiveness is escalating. Which nursing intervention would be least helpful to this client at this time?

Initiating confinement measures Rationale: During the escalation period, the client's behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging the behavior, moving the client to a quiet area, and medicating the client as appropriate. It is not appropriate during this period to initiate confinement measures; this action is most appropriate during the crisis period.

A nurse plans outcomes for a client who is being treated for psychosis. Which of the following steps would be included during the stable or discharge phase of treatment?

Keeping the client active with hobbies, exercise, and work Rationale: Desired outcomes for a psychotic client during the stable or discharge phase of treatment include maintenance of a consistent sleeping pattern; avoidance of caffeine and alcohol; maintenance of daily and weekly routines, including enjoyable activities; and a regular medication schedule. Evaluation of neurological status, the use of directive communications, and the administration of acute psychotropic medications with the client are all active-phase interventions.

A client and her newborn infant have undergone human immunodeficiency virus (HIV) testing, and the results for both clients are positive. The news is devastating, and the mother is crying. What is the appropriate nursing action at this time?

Listen quietly while the mother talks and cries Rationale: This client has just received devastating news and needs to have someone present with her as she begins to cope with it. The nurse needs to sit and actively listen while the mother talks and cries. Calling an HIV counselor may be helpful, but it is not what the client needs at this time. The other options are not appropriate for this stage of coping with the news that both the client and her infant are HIV positive.

A nurse observes that a client is pacing back and forth. The nurse asks the client how she is feeling, and the client responds by telling the nurse that she feels "out of control!" Which intervention is most appropriate initially to maintain a safe environment?

Moving the client to a quiet room and talking about her feelings Rationale: The anxiety symptoms demonstrated by this client require some form of intervention. Moving the client to a quiet place decreases environmental stimuli, and talking gives the nurse an opportunity to identify the cause of the client's feelings and determine the appropriate interventions. Seclusion or restraint is not appropriate.

A heroin addict who overdoses on the drug is brought into the emergency department. The client is having seizures, and the nurse notes that his pupils are dilated. Which of the following interventions does the nurse anticipate that the emergency department physician will prescribe?

Naloxone (Narcan) Rationale: An opioid antagonist such as naloxone would be prescribed to treat a heroin overdose to reverse central nervous system depression. Gastric lavage is used for oral overdose of or oral poisoning with certain substances. Intravenous fluid is a general intervention in many situations. Ammonium chloride is used to acidify the urine of a client who overdoses on amphetamines

A nurse is preparing to provide nursing unit information to a client who does not speak English who is being admitted to the mental health unit. Which action is best for the nurse to take to ensure that the client understands the information?

Obtaining a hospital interpreter to communicate with the client Rationale: Obtaining a hospital interpreter to communicate with the client is the best action because it will ensure that the client clearly understands the nursing unit information. Asking a family member to translate is not appropriate, because the nurse cannot be sure that the client is receiving the correct information. It is inappropriate to ask a hospitalized client to translate. Again, the nurse cannot be sure that the client is receiving the correct information, plus this action may violate both clients' rights to privacy and confidentiality. Providing the client with a pamphlet that explains the nursing unit information in the client's language may be an additional method of providing information but should not be the only method.

A nurse is admitting a client with a diagnosis of anorexia nervosa to the mental health unit. Which of the following characteristics is a hallmark of this disorder?

Personal relationships tend to become more superficial and distant. Rationale: As anorexia nervosa develops, personal relationships tend to become more superficial and distant. Social contacts are avoided because of the fear of being invited to eat and being discovered. The client is preoccupied with food and meal planning (especially for others), his or her own caloric intake throughout the day, and ways to avoid eating. Anorexic persons are likely to become very emaciated and do not maintain a near-normal body weight.

A client is admitted to the medical-surgical unit of a hospital, and suicide precautions are taken until the client can be admitted to the psychiatric unit. Which nursing intervention does the nurse implement?

Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping an arm's distance from the client at all times Rationale: When a client is suicidal, someone must be at arm's length at all times, observing the client, and the client must be in view at all times, even while toileting and showering. Plastic utensils are used for eating. A semiprivate room is better than isolation in a private room. Searching the client and the client's room for harmful objects is done openly and randomly. Glass mirrors are removed and the bathroom is harmproofed by replacing the metal shower curtain rod with a plastic rod that falls when 50 pounds of pressure is placed on it. Off-unit passes are not issued when a client is suicidal.

A male client reports difficulty concentrating, outbursts of anger, and a feeling of being keyed up all the time and states that peer relations are poor. He then tells the nurse that the symptoms started after his best friend was killed in the terrorist attack at the World Trade Center. The nurse suspects that the client is experiencing:

Post-traumatic stress disorder Rationale: Post-traumatic stress disorder (PTSD) is a response to an event that would be markedly distressing to almost anyone. Characteristic symptoms include a sustained level of anxiety, difficulty sleeping, irritability, difficulty concentrating, and outbursts of anger. Social phobia and panic disorder are characterized by specific fear of an object or situation. Obsessive-compulsive disorder involves some repetitive thought or behavior.

A mental health nurse is conducting the initial assessment of an obese client. The client confides that she was sexually molested at age 7 and began putting on weight thereafter. The nurse determines that the client's symptoms are compatible with a somatization disorder and recalls that obesity for this client most likely represents:

Protection from the risk of intimacy Rationale: Clients who become obese after a trauma such as the one described in the question may be trying unconsciously to present themselves as unattractive as a means of protecting themselves from the danger of intimacy. The client's symptoms are not compatible with satisfaction with self or functional coping. There is not enough information in the question to indicate a long-term lack of compliance with weight programs.

A client is admitted to the psychiatric unit after a serious suicide attempt involving a drug overdose. The priority nursing intervention is to:

Remain with the client at all times Rationale: Drug overdose constitutes a serious suicide attempt. The plan of care must comprise actions that will promote the client's safety. Constant observation by a staff member who is never less than an arm's length away is the best action. Requesting that a family member remain with the client at all times, removing the client's clothing and dressing the client in a hospital gown, and placing the client in a seclusion room from which all potentially dangerous articles have been removed are all inappropriate actions. It is not a family member's responsibility to safeguard the client. Removing one's clothing does not ensure safety, and it minimizes the client's dignity. Seclusion is used as a last resort for clients who are aggressive or violent and a threat to self or others.

A client with obsessive-compulsive disorder who continually cleans her room with paper towels becomes enraged with her roommate for throwing the package of paper towels into the waste basket, begins to yell, and slaps the roommate. Which of the following actions would the nurse take first?

Removing both clients to safe locations Rationale: The first responsibility of the nurse is to ensure the safety of all clients. Removing each client to a safe location is the only option that fulfills the needs of both of the clients in the question. The other actions are either contraindicated (i.e., restraining the client) or are of lesser priority (i.e., filling out an incident report, which may not be indicated, depending on the level of injury to the second client, and calling the hospital's risk-management department).

A client is admitted to the psychiatric inpatient unit and suicide precautions are instituted. Which of the following interventions does the nurse implement?

Removing perfume, shampoo, and other toiletries from the client's room Rationale: When suicide precautions are instituted, all of the client's belongings that are potentially harmful are removed and placed in a locked area from which the nursing staff can retrieve them as the client needs to use them. Visitors are not restricted. However, any items that a visitor brings to the client must be checked by the nurse. Glass items are not placed in the suicidal client's room.

A nurse is caring for a client who has been identified as a victim of physical abuse. Which of the following actions is the priority as the nurse plans care for the client?

Removing the client from any immediate danger Rationale: Whenever the abused client remains in the abusive environment, priority must be placed on determining whether the person is in any immediate danger and, if so, taking emergency action to remove the client from the situation. Notifying the caseworker of the situation, adhering to mandatory abuse reporting laws, and obtaining treatment for the abusing family member may be appropriate interventions but are not the priority.

A client in a mental health unit gets into a fight with another client over the use of the public telephone on the unit. The client is accused of making two telephone calls and staying on the telephone for 1 hour. Which of the following interventions by the nurse would be most therapeutic?

Saying to the clients, "You may each use the phone for 10 minutes. I will time the calls for both of you. Do you both agree to abide by my decision?" Rationale: The most therapeutic intervention is the one in which the nurse gives an alternative solution and asks for the clients' cooperation. If this approach fails, the nurse must eliminate the phone privilege for both clients and give time-outs to deescalate the situation. Taking telephone privileges away from both clients for the day and giving them time-outs in their rooms is nontherapeutic because the nurse is not being empathetic. In stating, "Okay, this is the last straw. Neither of you may use the telephone until tomorrow, and then only with a nurse timing you," the nurse displays anger and is nontherapeutic in punishing the clients. In responding, "Go to your rooms, both of you. I don't want to hear anything more about the telephone on this unit for at least 2 hours," the nurse is nontherapeutically authoritarian and does not provide empathy.

A schizophrenic client arrives for a scheduled appointment with the mental health nurse. The nurse notes that the client's hygiene is poor and that the client is having difficulty concentrating on what the nurse is saying and responding appropriately. Which nursing intervention would be most appropriate?

Saying, "I notice that you don't seem to be caring for yourself. Are you taking your medication?" Rationale: When the nurse's observations indicate that the client is noncompliant with his medicine, the most appropriate intervention is the one in which the nurse makes observations and assesses noncompliance. Saying nothing and contacting the psychiatrist to sign a commitment order is inappropriate. Commitment proceedings may be necessary if the client is a danger to self or others. Giving the client his antipsychotic medication and asking him to return in the morning for a follow-up visit is inappropriate because the client needs assessment and intervention immediately. Waiting until the next morning does not meet the client's immediate needs. In asking, "Will you voluntarily admit yourself for a couple of days so that you can straighten out your medicine and thinking?" the nurse asks the client to enter the hospital voluntarily. This intervention is premature, because further assessment of the client is needed.

A homeless client with an antisocial disorder is brought to the emergency department by the police after disturbing customers in a department store. The client says to the nurse, "I need to be hospitalized. It's getting cold out, and I need a warm bed. If you don't get me into a hospital, I'll jump off a bridge." Which nursing intervention would be therapeutic?

Sending the client to a shelter that will provide temporary housing if he signs a contract agreeing not to attempt suicide Rationale: The client is clearly using suicide as a threat so that he will be hospitalized. As long as self-harm is not an issue, providing the client with shelter will meet his needs. Sending the client to the psychiatric hospital intake center immediately for evaluation is an intervention that should be used if the client refuses to sign a contract for "no suicide." Guaranteeing the client a hospital bed if he shows up for a follow-up appointment is manipulation, which is a nontherapeutic intervention. The nurse would not order the police to arrest a client.

A nurse notices a paranoid stare during a conversation with a client. The client then begins to fidget and gets up to pace around the room. Which of the following actions by the nurse would be beneficial?

Sharing the observation with the client and helping the client recognize and acknowledge his or her feelings Rationale: Sharing observations with clients may help them recognize and acknowledge their feelings. Moving the client to a quiet room or changing the subject will not help a client recognize his or her behaviors and feelings. Allowing the client to pace provides no assistance and may lead to their becoming out of control.

A schizophrenic client says, "I feel like I'm rotting away inside and all of my organs are rusting." Which type of delusion does the nurse identify in the client's statement?

Somatic Rationale: Somatic delusions are false beliefs that one's body is changing in an unusual way, such as rusting or rotting away. The most therapeutic intervention in such a situation is to gain the client's cooperation in taking the antipsychotic medication prescribed by the psychiatrist. A delusion of jealousy is the false belief that one's significant other is being unfaithful. A delusion of persecution is the false belief that one is being singled out for harm by others. This usually takes the form of a plot by individuals in power against the person. A client subject to ideas of reference misconstrues trivial events and remarks so that he or she may attach personal significance to them.

A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathologic conditions. It is important for the nurse planning care for this client to understand that the client is afflicted with:

Somatization disorder Rationale: Somatization disorder is characterized by a long history of multiple problems with no organic cause. This characteristic is not found in clients with the other mental health disorders listed.

A nurse is trying to deescalate aggressive behavior exhibited by a client with schizophrenia. Which nursing action would be contraindicated in this situation?

Standing close to the client and telling the client that the behavior is unacceptable Rationale: To deescalate aggressive behavior, the nurse should maintain calm and a nonaggressive posture. The nurse should also give the client clear instructions that are brief and assertive and negotiate options with the client. Negotiation of options allows the client to feel that he or she has some room in making decisions. The nurse needs to maintain personal space and should not stand closer than about 8 feet from the client, which would convey a threatening message.

An adolescent is returning home after an acute psychiatric hospitalization for a suicide attempt. Which of the following strategies will be least effective in preparing the client for discharge?

Suggesting that the client's mother quit her job Rationale: Suggesting that the client's mother quit her job is clearly the least effective option because it disrupts family processes. Encouraging the sharing of feelings, identifying the family's strengths and weaknesses, and offering and providing the family options and resources are helpful ways of enhancing the family processes.

A nursing instructor enters a classroom to begin class and finds two students yelling and physically assaulting each other. Which intervention by the instructor would be most appropriate?

Telling the class to go to the nursing laboratory at once, then asking a student to tell the nursing secretary to have security come to the classroom, and asking the students who are fighting to stop fighting and take their seats Rationale: The first concern is to ensure student safety, so in the correct option the students are directed to go to the nursing laboratory. Someone is asked to notify security, and then the instructor determines whether the students who are fighting can obey the direction to stop and take a seat. Leaving the classroom without attempting to verbally direct the students to stop fighting results in an unsafe environment for the students who are fighting. Although closing the classroom door might be helpful in discouraging other students from watching the fight, it is not generally considered a safe intervention to bar access to an exit when violence has erupted.

A nurse caring for a schizophrenic client is assessing the client's ability to control distorted thought processes. Which of the following findings indicates a positive outcome?

The client can identify the recurrence of hallucinations, can refrain from responding to them, and reports a significant decrease in the incidence of hallucinations. Rationale: Identifying the reoccurrence of hallucinations, refraining from responding to them, and reporting a significant decrease in the incidence of hallucinations are all positive client outcomes. Other positive outcomes include appropriately interacting with others, demonstrating thinking that is based in reality, and grasping others' ideas. The other options are incorrect because they are not positive outcomes with regard to the client's ability to control distorted thought processes and focus on the reality of the distorted thought processes.

A nurse is collecting data from a client in crisis and assessing the potential for self-harm. Which of the following findings indicates that the client is at high risk for suicide?

The client has an immediate plan for a suicide attempt. Rationale: Clients at high risk for suicide include those with a history of a dual diagnosis of mental illness and substance abuse, a personal or family history of suicide attempts, depression, alcoholism, and psychotic episodes. Having a plan, however, particularly involving a method that is immediate and available, puts the client at very high risk. The client may have lethality potential if he or she appears impulsive and disorganized, but these two findings are not as immediately alarming as a suicide plan.

A nurse working in the emergency department is performing an initial assessment on a client, and notes many physical injuries. The nurse suspects family-related violence. Which of the following findings are specific to this type of violence?

The client lives with one of their children and requires extensive assistance with activities of daily living. Rationale: Clients who are at risk for family-related violence include those who are dependent on others or who require extensive care with activities of daily living. The client living in an assisted living facility is relatively independent and requires minimal assistance. The client who is financially dependent on him or herself is not considered to be a risk factor for family-related violence. The client who relies on neighbors and friends for transportation are also not considered to be at risk for this type of violence.

A furious and aggressive client is put in restraints and told that the restraints will be removed once the she regains control. At which of the following times is removal of the restraints by the nurse appropriate?

When no acts of aggression are observed in the hour following the release of two extremity restraints Rationale: The best indicator that the behavior is under control is that the client exhibits no sign of anger or aggression after being partially released from the restraints. After medication that has been administered has taken effect, the nurse explores with the client the reasons for the angry and aggressive behavior. An apology from the client is not an indication that it is safe to remove the restraints.