Mood and Affect

Which response is the most therapeutic to give a client who says. 'If I have a colon resection and colostomy, i know that my husband will never come near me again'?

'You're concerned about how your husband will respond to you surgery.'

Which response would the nurse make to a client with the diagnosis of bipolar disorder who tells the nurse, ''I've hidden a razor blade, and tonight I'm going to kill myself'?

'You're going to kill yourself?'

When a client is clearly demonstrating a crisis behavior, which client-focused intervention would the nurse implement first?

Determine the client's present state of mind

Which initial behavior would the nurse help a client with major depressive disorder complete?

Develop rapport with the nurse

Which action would the nurse use to establish a therapeutic relationship with a withdrawn, reclusive client?

Help the client keep anxiety to a minimum

Which intervention would the nurse ass to the plan of care for a moderately depressed client?

Offering the client the opportunity to make some decisions

Which activity would the nurse suggest for a moderately depressed client?

Participating in aerobic exercise

Which signs and symptoms would the nurse observe in a client with bipolar disorder, depressed episode?

Paucity of verbal expression related to slowed thought processes

Which symptoms presented by the client necessitate the prescription of lithium salts

Periodic swings of mania and depression

A client has several episodes of uncontrolled rage. While watching violent behaviors on a television newscast, the client says, 'Those people need to be put away before they kill someone.' Which defense mechanism is the client using

Projection

Which initial action would the nurse take for a client with bipolar I disorder, manic episode who becomes loud and vulgar and disturbs the other clients?

Take the client to a large, quiet area to walk

The nurse is caring for clients who are in the terminal stage of illness. The nurse becomes aware of feeling depressed when coming to work. Which would the nurse do?

Talk with other nurses on the unitt

The nurse identifies that a client seems to be depressed after a thymectomy for treatment of myasthenia gravis. Which action would the nurse take?

Talk with the client and emphasize activities the client is still able to perform

Which response would the nurse use for a client who appears dejected, barely responds to questions, and in a barely audible voice says, 'Life is no longer worth living'?

'Have you been thinking about suicide?'

Which question would the nurse ask to obtain information about a bulimic client's intake habits and patterns?

'How often are you eating in response to your feelings rather than because you're hungry?'

Which statement of a client confirms that he or she has reached the intimacy versus isolation stage according to Erikson's theory of psychosocial development?

'I did so much for my partner, but i was dumped for someone more attractive'

Which response would the nurse make to a client with depression who is sitting by the window crying?

'You seem to be experiencing a sad moment. I'll sit here with you for a while and talk it you would like.'

A client has a halo fixation device with a body cast place after sustaining a cervical neck injury. Which statement indicates the client's concern about body image has been resolved successfully?

'I've gotten used to the brace. I may even miss it when it's gone.'

Which response would the nurse make to a depressed client who tells the nurse, 'I want to die'?

'You would rather not live.'

Which statement would the nurse make to a newly admitted, depressed, tearful client who looks intently at the nurse but says nothing when the nurse offers to walk with the client to the lunch table?

'It much be very difficult for you to be on a psychiatric unit'

Which response would the health clinic nurse make to a young college student who reports increasing anxiety, loss of appetite, and an inability to concentrate?

'It's been difficult for you, How long has this been going on?'

Which response would the nurse expect from a client with antisocial personality disorder?

'Society makes people follow rules that don't apply to me.'

A client who has severe facial scarring from burns tells the nurse, 'I've saved some oxycodone, and when i get home, I'm going to take all of them. Don't tell anyone.' Which response is best?

'Are you planning to kill yourself?'

Which statement would the nurse make when discharging a depressed client from the mental health unit?

'Call the contact number we gave you if you have an emergency'

Which complication is an adverse effect of cortisone therapy?

Behavioral changes

Which medication causes euphoria and hallucinations in an addicted adolescent but does not show any physical effects when withdrawn abruptly?

Cannabis

Which defense mechanism is most often used by parents who abuse an infant or toddler?

Displacement

Which signs and symptoms would the nurse find in a client who is in the depressive phase of bipolar I disorder

Apathy Loss of appetite Sleep disturbances

What finding about an adolescent may require further evaluation with a SLAP assessment?

Suicidal ideation

Which intervention would be essential for the nurse to take for a hyperactive client?

Using a form but caring and consistent approach

A female client who had a colostomy recently is asking questions about how normal her life will be now that she has a colostomy. Which statement by the client indicates a need for further teaching?

'I wanted another child, and now pregnancy is not an option for me'

Which best response would the nurse make to a client with severe anxiety who starts to cry uncontrollably while talking with the nurse?

'It's okay to cry; I'll just stay with you for now.'

The nurse is teaching a group of student nurses about psychotherapeutic medication in older adult clients. Which statement made by a student indicates to the nurse that additional teaching is required?

'Low serum levels of the medication are reported in older adult clients on psychotherapeutic medication.'

Which response is best to give a parent who asks about childhood suicide?

'Suicide threats from children of any age should be taken seriously'

Which response would the nurse make to help a depressed client who is crying?

'Tell me what you're feeling now.'

Family members of a client who has a brain attack (cerebrovascular accident, CVA) ask why the client cries easily and without provocation. Which explanation would the nurse provide about the client's behavior?

Has little control over this behavior

Which action would the nurse take for a frail depressed, older client who frequently paces the halls and becomes physically tired from the activity?

Have the client perform simple, repetitive tasks

Which factor would be imprtant when selecting a room for a client with bipolar I disorder who is hyperactive and talking nonstop in a loud, demanding voice?

A quiet and restful atmosphere

Which action would the nurse take when working with a client who is depressed?

Accept what the client says

Which approach would the nurse use for a client with major depression who refuses to participate in unit activities, claiming to be 'just too tired'?

Accepting the client's feelings about activities while calmly setting firm limits

After a spontaneous abortion at 5 months, a client is depressed and describes how the child would have looked and how bright he would have been. Which grief pattern is the client demonstrating?

Acte grieving

Which behavior would the nurse identify that a client with histrionic personality disorder is displaying when after being refused a sleeping pill, the client throws a book at the nurse?

Acting out

Which initial intervention would be implemented when a depressed client says. 'I'm no good, I'm better off dead'?

Alert the staff to schedule a 24-hour observation of the client

Which sedative-hypnotics would the nurse identify as being used to treat insomnia associated with a panic disorder?

Alprazolam and Clonazepam

Which statements listed by the nursing student are appropriate regarding theories related to temperament?

An easy child is open and adaptable to change A difficult child requires a more structured environment A difficult child shows an intense and primarily negative mood.

Which technique would the nurse implement to provide suicide precautions for a newly admitted suicidal client?

Assigning a staff member to be with the client at all times

Which cellular process associated with type 1 diabetes mellitus results in increased client fatigue?

Decrease production of insulin by the pacreas

For a client with the diagnosis of major depression, which problem is the most common?

Decreased social interaction

Which behavior would the nurse observe in a child with oppositional defiant disorder

Deliberately annoys others

Which behavior would alert the school nurse that a second-grader has ADHD?

Impulsivity

Which action would a group of nursing students take when a client with bipolar disorder, manic episode, tells them 'I'm being held against my will, and I plan to escape later today'?

Inform the primary nurse of the client's behavior and plan

For a client with bipolar I disorder, manic episode, which factor would be considered to meet rest and sleep needs?

Is easily stimulated, and this interferes with sleep

For a client with the diagnosis of borderline personality disorder, which problem is most likely to underlie angry or hostile behavior?

Low self-esteem

Which objective would be a priority for a young child with ADHD who demonstrates intermittent head-banging and hair-pulling

Maintaining safety

Which explanation is true for childhood depression?

May appear as acting-out behavior

While caring for a client on phenelzine, the nurse notes an excess elevation of the person's temperature. Which medication being taken concurrently by the client may be responsible for this condition?

Meperidine

Which intervention would the nurse implement for a client with delirum?

Providing consistency

During an assessment the client mentions taking cefotetan and drinking a few cocktails at dinner. Which symptoms might be explained by this medication-alcohol interaction?

Pruritus Diaphoresis Hypotension Stomach cramps Chest pain

Which clinical manifestation is associated with depression?

Psychomotor retardation

Which safety intervention would the nurse include in a plan of care for a client with somatic disorder who reports loss of vision?

Put the call light within reach Orient the client to surroundings

A client falls at home and is brought to the emergency department by family members. The client reports intercostal pain and is confused and disoriented. Which is the best way for the nurse to determine whether confusion is new for the client?

Question the family members about the client's usual behavior

Which response would the nurse taken when a client comes up and shouts, 'I hate you> You're talking about me again!' and throws a glass of juice at the nurse who is talking to another client?

Removing the client from the room because limits must be place on such behavior

The nurse is caring for a client who was brought to the ER after binge drinking at a party. Which interventions would the nurse include in the plan of care to prevent a suicide attempt?

Require sitter in room at all times Verify medications are swallowed Use plastic utensils and paper cups

The nurse finds that a client perfers Reiki to antidepressants for treatin depression. Which intervention of the nurse indicates open-mindedness

Respecting the client's preferences

Which behavior would alert the nurse that a child is demonstrating outwardly focused anger and aggression in an overt manner?

Scribbling on a classmate's art assignment

A client who is extremely depressed after losing his job because of downsizing says, 'I'm a useless, worthless person, No wonder I lost my job.' Which feeling state is the client expressing?

Self-deprecation

Which action would the nurse take for a toddler with autism spectrum disorder who is sitting in a corner, rocking and spinning a top?

Sit with the toddler while watching the spinning top to provide a nonintrusive presence

The grieving spouse of a client who has just died says 'We should have spent more time together. I always felt that my work come first' Which interpretation would the nurse make?

Spouse is expressing feelings of guilt over lost opportunities

Which response would the nurse make to a client with a borderline personality disorder who criers bitterly and pounds the bed in frustration after a conference with the primary health care provider?

Stay with the client and listen attentively if the client wishes to walk about the problem

Which action would the nurse take for a withdrawn client who refuses to get out of bed and becomes upset when asked to do so?

Stay with the client until the client calms down

The spouse of a client who had a cerebrovascular accident asks the home health nurse why the client cries easily and without provocation. Which response would the nurse provide?

This behavior is a common response over which the client has little control

Which long-term outcome would the nurse add to the plan of care for a client experiencing a major depressive espisode?

Will verbalize realistic perceptions of self and others

One week after an above-the-knee amputation, a client refuses to go to physical therapy and tells the nurse, 'I'll never be a whole person again!' Which response would the nurse make?

You've lost a part of yourself. That must be difficult for you.

Which are the characteristics of the phallic stage, per Freud's psychoanalytical model of personality development?

A child may develop an oedipal complex, a girl may experience 'penis envy' feelings, the genital organs are the focue of pleasure

Which short-term goal would be most appropriate for a patient with phobias about elevators and large crowds who comes to the clinic for help because of feelings of depression related to these fears?

Describe the thoughts and feelings experienced in terrifying situations

During an admission interview, a client is expansive and distractible and demonstrates a fragmented, pressured, non-sequential pattern of speech. Which communication technique would the nurse use?

Closed questions

The nurse suspects that an adolescent has anorexia nervosa. Which characteristics may have been observed in the adolescent?

Denying illness, dismissing food, and maintaining rigid body control

The mother of an adolescent complains of strange behavior such as sitting alone in a room, being inactive, having a sad facial expression, and withdrawing from previously enjoyed activities. On inquiry, the nurse finds that the adolescent's parents were recently divorced. Which condition does the client likely have?

Depression

Which condition would be the priority to assess for during the initial appointment for a client with bulimia nervosa?

Depression

A client experienced a second spontaneous abortion and expresses anger toward the health care provider, the hospital and the 'rotten nursing care.' Which coping mechanism is the client displaying

Displacement

Which behavior is typical for antisocial personality disorder

Disregard for others

Which traits would be expected when a client is in the reorganization phase of rape-trauma syndrome?

Eating disorders Fear of being alone or in a crowd

The family members of a client with the diagnosis of cerebrovascular accident express concern that the client often becomes uncontrollably tearful during their visits. Which information would the nurse include in a response?

Emotional lability is often associated with brain trauma

Which action would the nurse take for a depressed client who often sleeps past the expected time of awakening and spends excessive time resting and sleeping?

Encourage client participation in daily activites

An adolescent has pinpoint pupils, respiratory depression, and cyanosis. Upon assessment, the school nurse observes needle marks on arms and legs. Which medication is the adolescent probably abusing

Narcotics

Which action would the nurse take to encourage the depressed client who has been in the hospital for 5 days to eat in the dining room for lunch?

Offer to accompany the client to the dining room

a client who is on long-term corticosteroid therapy after an adrenalectomy is admitted to the surgical ICU after being involved in a MVC. Which statement is an important concern for client safety?

Steroid therapy will need to be increased to avert a life-threatening crisis

Which diversion activity would the nurse encourage to meet the client's needs during the remission phase of his or her multiple sclerosis (MS)?

Swimming

The nurse recieves a telephone call from an adolescent who expresses suicidal ideations. Which client response indicates that the nurse can safely terminate the call?

The adolescent formulates an action plan to control self-harm behaviors.

A client is having a manic episode and has not eaten in the 2 weeks preceding hospitalization, Which rationale explains the eating problem?

The client's activity level interferes with eating

Which activity would the nurse encourage for depressed client who has feelings of failure and a low self-esteem?

assisting a staff member in working on the monthly bulletin board

Which strategy would be effective for a client with alcohol use disorder who says, 'Drinking is a way out of my depression'?

A self-help group

Which intervention would the nurse perform for an extremely agitated client who begins to pace around the mental health dayroom?

Letting the client pace in the hall away from other clients

For a client who is demonstrating manic behavior, which behavior is the most important to monitor?

Excessive activity may cause exhaustion

Which behavior would the nurse observe in a client who has a histrionic personality disorder?

Extroverted and dramatic

Which action would the nurse take when a young adult client becomes very agitated after the parents' visit?

Explore the client's response to the parents' behavior

Which conclusion would the nurse make when the depressed client says, 'You know I'm a sorry, lazy person. I don't deserve a job'?

Has feelings of self-deprecation

Which action would the nurse take to minimize psychological stress in an anxious client who has been admitted to the psychiatric unit?

Learn what is of particular importance to the client