(N129/3) Practice Exam

A couple arrives at the mental health clinic for counseling because the husband consistently believes that his wife is having multiple affairs. After several sessions a delusional disorder is diagnosed. What specific subtype of the delusion does the nurse identify? 1. Jealousy 2. Somatic 3. Grandiose 4. Persecutory

1 Rationale: A client who is convinced that a mate is unfaithful exhibits delusional jealousy. Somatic delusions concern preoccupation with the body, including complaints of disfigurement, nonfunctioning body parts, insect infestation, and presence of a serious illness. In a grandiose delusion, the client seeks a position of power by expressing an exaggerated belief in his or her importance or identity. Clients with persecutory delusions believe that they are being conspired against, spied on, drugged, or poisoned.

Electroconvulsive therapy (ECT) is a mode of treatment that is used primarily to treat what? 1. Clinical depression 2. Substance abuse disorders 3. Antisocial personality disorder 4. Psychosis occurring in schizophrenia

1 Rationale: ECT is used to treat clinical depression in clients who do not respond well to a trial of psychotropic medications or are so severely depressed that immediate intervention is needed. ECT is not used as a primary treatment for clients with substance abuse disorders, antisocial personality disorder, or schizophrenic psychosis.

An older client whose spouse has died is sitting alone in a lounge in the nursing home and says, "I'm all alone; no one has any use for me." Which response by the nurse is most therapeutic? 1. "You seem upset. Let's talk about what's bothering you." 2. "We need to be alone sometimes. It helps us get to know ourselves better." 3. "Try doing something to avoid feeling lonely. I think you should socialize more." 4. "You should focus on ways to change this. Let's play some games to improve your morale."

1 Rationale: Saying "You seem upset. Let's talk about what's bothering you" is a therapeutic approach that indicates an awareness of the client's feelings and encourages verbalization. Moralizing is a barrier to effective communication. Telling the client to do something to avoid feeling lonely and advising to socialize more conveys a judgmental or critical attitude toward the client. Telling the client to focus on ways to change the problem and suggesting playing games to improve morale is diverting the client's attention to something other than feelings.

An older nursing home resident with the diagnosis of early-onset dementia likes to talk about the old days and at times has a tendency to confabulate. What does the nurse determine is the purpose of the client's confabulation? 1. Prevent regression 2. Increase self-esteem 3. Attract the attention of others 4. Help him reminisce about achievements

2 Rationale: Confabulation is used as a defense mechanism against embarrassment caused by a lapse of memory; the client fills in the blanks in memory by making up details, thus maintaining self-esteem. Regression is a defense mechanism in which the individual moves back to earlier developmental defenses; the client is not regressing at this time. Although older adults fear being forgotten or losing others' affection, this is not the reason for confabulation. Confabulation is not used to reminisce about past achievement.

The nurse is developing a plan of care for a client who is using ritualistic behavior. Initially the nurse must understand what about the ritual? 1. That it is under conscious control 2. That it is used primarily for secondary gains 3. That it helps the client focus on the inability to cope with reality 4. That it helps the client control the level of anxiety the client is experiencing

4 Rationale; The rituals help control anxiety by maintaining a set pattern of action. The reason for the ritual is under unconscious control. Rituals are generally seen by the client as illogical; they provide few secondary gains. Rituals are a means of diverting attention from an anxiety-producing situation.

Slurred speech is associated with _______.

opioids

Signs and symptoms of alcohol withdrawal begin within ____ hours of cessation or a decrease in alcohol consumption, peak in _______ hours, and usually begin to ease after ____

12 48 to 72 4 or 5 days.

After 3 weeks of mental health therapy a client tells the nurse, "I feel ready to go home." How can the nurse best evaluate the client's readiness for discharge? 1. By questioning the client's level of trust in self and staff 2. By requiring the client to explain any changes in behavior since admission 3. By asking the client to identify specific behaviors as examples of wellness 4. By having the client's family and friends provide feedback about changes in behavior

3 Rationale: Asking clients to identify positive changes can reinforce those changes and help the client prepare for discharge. Questioning the client's level of trust in self and staff may be viewed as a lack of trust and undermine readiness for discharge. Pressuring the client to explain behavioral changes increases anxiety and the need to use defenses. Information received from family and friends is not as relevant as the client's perceptions of progress.

____________ is characterized by the presence of one or more symptoms related to a neurological problem that has no organic cause.

Conversion disorder

__________ is characterized by the reporting of many physical problems by the client, usually beginning before age 30; physical problems may include pain, gastrointestinal symptoms, sexual or reproductive problems, and at least one symptom that suggests a neurological disorder.

Somatization disorder

A client with a borderline personality disorder becomes hostile and calls the nurse names. When the nurse denies privileges, the client states that the nurse is uncaring. How can the nurse be most therapeutic in this situation? 1. Helping the client identify feelings 2. Increasing the client's limits on privileges 3. Avoiding the client until the hostility is resolved 4. Advising the client how to approach people differently

1 Rationale: To be most therapeutic the nurse needs to help the client identify feelings, thereby aiding self-understanding. Increasing the limits on the client's privileges is a hostile response by the nurse. Avoiding the client will increase the client's hostility. The nurse should never give advice to clients; the nurse's role is to facilitate the client's problem-solving abilities.

_____________________ are early signs of withdrawal from alcohol.

Anorexia, nausea, and vomiting

panic attacks are associated with _________.

hallucinogens

What clinical findings may be expected when a nurse assesses an individual with an anxiety disorder? Select all that apply. 1. Worrying about a variety of issues 2. Acting out with antisocial behavior 3. Converting the anxiety into a physical symptom 4. Displacing the anxiety onto a less threatening object 5. Demonstrating behavior common to an earlier stage of development

1, 3, 4, 5 Rationale: Excessive anxiety and worry about a number of events, topics, or activities for a 6-month duration are the hallmark of generalized anxiety disorder. Converting anxiety into a physical symptom is an example of a conversion disorder, which eases anxiety. Displacing the anxiety onto a less threatening object, which eases anxiety, is typical of a phobic disorder. Regression is an attempt during periods of stress to return to behavior that has been satisfying and is appropriate at an earlier stage of development. Acting out anxiety with antisocial behavior is most commonly found in individuals with personality rather than anxiety disorders.

A nurse working on a detoxification unit has clients who are in active withdrawal from alcohol, opiates, benzodiazepines, cocaine, and marijuana. Place these clients in order, from the one with the highest risk for life-threatening physiologic withdrawal to the one with the lowest risk: 1. An adolescent who is withdrawing from cocaine 2. An older adult who is withdrawing from alcohol 3. A middle-aged adult who is withdrawing from marijuana 4.A young adult who is withdrawing from a long-acting benzodiazepine

2, 4, 1, 3 Rationale: Older adults possess fewer physiological reserves and are at the highest risk for life-threatening withdrawal, especially from a drug, such as alcohol, that has a short half-life. Long-acting benzodiazepines, although potentially lethal in withdrawal, will be less of a problem in a young adult because young adults have greater physiologic reserves than do older adults. Cocaine is not lethal during withdrawal unless clients intentionally hurt themselves. Marijuana has minimal physiologic withdrawal symptoms because of its long half-life.

A client with a history of heavy drinking is brought to a psychiatric facility in a stupor. On the day after admission the client is confused, disoriented, and delusional. What alcohol-related symptom does the nurse decide the client may be experiencing? 1. Amnesia 2. Hallucinations 3. Withdrawal syndrome 4. Uncomplicated dementia

3 Rationale: The central nervous system is affected by the abrupt withdrawal of alcohol intake, resulting in the classic responses indicated in the situation; they occur 1 to 3 days after the cessation of alcohol intake. The information presented does not indicate the presence of impaired short- or long-term memory or of hallucinations. There are insufficient data with which to identify dementia; impairment of thought processes, judgment, and intellectual abilities must continue for 3 weeks or longer for dementia to be considered as a diagnosis.

Encouragement and appropriate praise should be given to hyperactive clients to help them increase their feelings of self-esteem. When they have acted appropriately, what is the best statement for the nurse to make in an effort to let them know of their improvement? 1. "You behaved well today." 2. "I knew you could behave." 3. "Everyone likes you better when you behave like this." 4. "Your behavior today was much better than it was yesterday."

1 Rationale: "You behaved well today" simply states a fact and delivers praise without making demands. "I knew you could behave" puts the total responsibility for control on a client who needs to have external controls set. "Everyone likes you better when you behave like this" does not help the client separate the self from the behavior; it tells the client that acting-out behavior will result in rejection. The client may not recall what happened yesterday and may not know why today's behavior is better.

The nurse suggests counseling for a 13-year-old whose close friend has just committed suicide. The nurse's intervention is based on the understanding that an adolescent is at risk for copycat suicide mainly because members of this age group exhibit which characteristic? 1. Generally have poor impulse control 2. Have had few experiences with mortality 3. Often forge very close peer relationships 4. Typically mimic the behavior of their peers

1 Rationale: Adolescents are at especially high risk because of the immaturity of the prefrontal cortex. This is the portion of the brain that is responsible for judgment and impulse control. Although lack of life experience, the closeness of peer relationships, and behavioral mimicking are all characteristics of this age group, they are not as influential in a behavior such as copycat suicide.

A nurse in charge in the surgical intensive care unit notes that a number of clients do not seem to be responding to morphine that was administered for pain. Later in the evening the nurse finds a staff nurse dozing in the nurses' lounge. When awakened, the staff nurse appears uncoordinated and drugged, with slurred speech. What should the nurse in charge do? 1. Ask the nurse manager to be present before confronting the staff nurse. 2. Ask other staff members whether they have noticed anything unusual lately. 3. Tell the staff nurse that everyone now knows who has been stealing the morphine. 4. Arrange to secretly observe the staff nurse the next time the staff nurse administers morphine.

1 Rationale: Arranging for the nurse manager to be present before confronting the staff nurse is important because this is a serious allegation, and confrontation should occur in the presence of a person in a supervisory position. Asking other staff members whether they have noticed anything unusual is unprofessional. The nurse in charge has enough information to confront the other nurse. Telling the staff nurse that everyone now knows who has been stealing the morphine may result in an altercation; a witness should be present. Arranging to secretly observe the staff nurse the next time the staff nurse administers morphine is unprofessional; the nurse in charge has a legal responsibility to intervene.

A delusional client refuses to eat because of a belief that the food is poisoned. What is the most appropriate initial nursing intervention? 1. Stating that the food is not poisoned 2. Tasting the food in the client's presence 3. Showing the client that other people are eating without being harmed 4. Telling the client that tube feedings will be started if she doesn't start eating

1 Rationale: Clients cannot be argued out of delusions, so the best approach is a simple statement of reality. Tasting the food in the client's presence is a form of entering into the client's delusions; the client may feel that only a particular part of the meal is free of poison. Showing the client that other people are eating without being harmed is trying to argue the client out of the delusion and will not work. The client can formulate a reason ("They have the antidote") to continue the false belief. Threats are always inappropriate nursing interventions.

When working with a client who is in an alcohol detoxification program, what nursing action is most important? 1. Address the client's holistic needs. 2. Support the client's need for nurture. 3.. Discuss with the client the negative effects of alcohol. 4. Promote the client's compliance with the program through gentle prodding.

1 Rationale: Clients who abuse alcohol characteristically have multiple nursing care needs, among them physiological, psychological, social, and occupational. Although nurture is important, this client must learn self-reliance. Discussing with the client the negative effects of alcohol is probably an old story to this client and will have a minimal positive effect. Promoting the client's compliance with the program through gentle prodding will not provide an atmosphere that can help the client withstand the stress of the detoxification program.

What is a frequent finding in clients with paraphiliac disorders? 1. Other covert or overt emotional problems 2. Gonadal and pituitary hormone deficiencies 3. Overassociation with society's fringe groups 4. Inadequate development of the sexual organs

1 Rationale: Clients with paraphiliac disorders usually have many other emotional problems, either overt or covert in nature. There is no proof of a deficiency of gonadal and pituitary hormones in connection with paraphiliac disorders. A link between overassociation with society's fringe groups and paraphiliac disorders has no basis in fact. Sexual organs in individuals with paraphiliac sexual disorders are not inadequately developed.

On the morning of a scheduled visit the parents of a client hospitalized for incapacitating obsessive behavior call to say that they cannot come because of problems with the accountant for their small business. The client appears upset and goes into elaborate detail about the parents' business and the monthly visit of the accountant. What is the best response by the nurse? 1. It's disappointing to have plans change at the last minute." 2. "Would you like to talk about what you'd planned to do today?" 3. "Would you like to make new plans now that they're not coming?" 4. "It's good that you can recognize that your parents are sometimes busy."

1 Rationale: Expressing understanding of the client's disappointment recognizes and supports these justified feelings and provides an opportunity for the client to ventilate further. Asking whether the client would like to talk about the now-scuttled plans or would like to make new plans ignores the client's feelings and directs communication away from the emotionally charged area. Complimenting the client for being able to understand that the parents are busy also ignores the client's feelings and directs communication away from the emotionally charged area.

Pt's partner died 36 months ago in an automobile accident returning from work. Pt stated that the partner "meanth everything to [them]." Their partner was responsible for making most of the big family decisions. Their relationship had began 10 years ago and it "had its problems but [the pt had] always tried to be forgiving." They have no childern. The pt's gried "has kept [them] from moving on with [their] life" A nurse is conducting an assessment interview with a client who has lost a life partner. In light of the information elicited, what does the nurse suspect about the client? 1. The client is experiencing dysfunctional grief. 2. The client is reacting inappropriately to a strong perceived loss. 3. The client has likely experienced a long history of chronic depression. 4. The client is progressing along the grief continuum identified by Kübler-Ross.

1 Rationale: Factors that contribute to dysfunctional grief include dependence on the deceased, the existence of unresolved conflict, and an unexpected or violent death. These factors are present in this scenario. A perceived loss is a one that is defined by the client but not obvious to others. This is not the case in this scenario. There is no evidence in the information to suggest a history of depression or poor coping mechanisms. Kübler-Ross stated that the suggested timeline of the five stages is 2 years, so this client is in protracted grief.

A depressed client on the psychiatric unit appears preoccupied and remains seated when it is time for the clients to go to lunch. What should the nurse do next? 1.Inform the client that it is lunchtime and lead the client to the dining room 2. Overlook the fact the client is not eating and leave snacks in the client's room 3. Tell the client that now is the time to eat because food will not be served later 4. Ask the client to choose whether to eat in the client's room or in the dining hall

1 Rationale: Preoccupied clients are usually not aware of external events. The client has not refused to eat; instead the client has simply not responded to external stimuli. Escorting the client to the dining room places the client in an environment where there is food. The client may be too preoccupied to eat anything; part of the intervention should be directed toward meeting the client's nutritional needs. The client probably will not respond to the warning that food will not be available later; also, this may be interpreted as a threat. Offering a choice may be immobilizing; depressed clients are often unable to make decisions.

Fourteen months after the traumatic death of a spouse, a client comes to the mental health clinic complaining of continuing depression and states, "I haven't been seeing any of my friends or attending any of the activities I previously enjoyed. My children are married and live in another state, and I almost never see them." What does the nurse determine that the client is experiencing? 1. Difficulty grieving 2. Ineffective family interactions 3. Problems in communicating with others 4. Low motivation to resume daily activities

1 Rationale; The client's grieving process is severe and extended, indicating dysfunction. There are not enough data to support the conclusion that the family's interactions are ineffective. The data do not indicate problems with communication; the client is communicating effectively with the nurse. Low motivation is not the reason for the client's inability to cope.

A nurse notes that a client in the detoxification unit is exhibiting early signs of alcohol withdrawal. What clinical manifestations might the nurse have noted? Select all that apply. 1. Tremors 2. Anorexia 3. Psychomotor agitation 4. Delusions 5. Confusion

1, 2 Rationale: Hand tremors, related to dysfunction of the nervous system, are an early sign of withdrawal from alcohol. Alcohol depresses the central nervous system, interferes with nerve conduction, and results in peripheral neuropathy. Signs and symptoms of alcohol withdrawal begin within 12 hours of cessation or a decrease in alcohol consumption, peak in 48 to 72 hours, and usually begin to ease after 4 or 5 days. Anorexia, nausea, and vomiting are early signs of withdrawal from alcohol. Alcohol affects the gastrointestinal system and can cause gastritis, pancreatitis, hepatitis, and cirrhosis. Psychomotor agitation is a late, not early, sign of alcohol withdrawal. Transient visual, auditory, and tactile hallucinations, rather than delusions, are associated with alcohol withdrawal. Confusion, disorientation, and impaired cognition are not early signs of alcohol withdrawal; alcohol withdrawal delirium occurs in less than 10% of those who experience the alcohol withdrawal syndrome.

A client is brought to the emergency department by friends because of increasingly bizarre behavior. Which signs does the nurse identify that indicate that the client was using cocaine? Select all that apply. 1. Euphoria 2. Agitation 3. Panic attacks 4. Slurred speech 5. Hypervigilance 6. Impaired judgmen

1, 2, 4, 5, Rationale: Cocaine is an alkaloid stimulant; euphoria or affective blunting, agitation or anger, hypervigilance, and impairment of judgment and social function are all associated with cocaine intoxication. Panic attacks are associated with hallucinogens. Slurred speech is associated with opioids.

The nurse and client have entered the working phase of a therapeutic relationship. What can the nurse expect the client to do during this phase? Select all that apply. 1. Initiate topics of discussion. 2. Focus the conversation on the nurse. 3. Repress emotionally charged material. 4. Accept limits on unacceptable behavior. 5. Express emotions related to transference.

1, 4, 5 Rationale: This phase is focused on developing the client's problem-solving skills while addressing the areas in the client's life that are causing problems. The nurse helps clients identify these topics for discussion. Focusing the conversation on the nurse occurs during the orientation phase, before trust is established. Repressing emotionally charged material occurs during the orientation phase, before trust is established. Resistant behaviors usually are overcome by the working phase. During the working phase of a therapeutic relationship trust is established on the basis of mutual respect. Once trust is established the client will feel comfortable enough to express feelings; feelings of transference and countertransference usually awaken during the working phase of a therapeutic relationship.

A client is admitted with the diagnosis of borderline personality disorder and possible depression. The client has a history of abusive acting-out behavior. What is most important to assess when caring for this client? 1. Degree of anger 2. Potential for suicide 3. Level of intelligence 4. Ability to test reality

2 Rationale: Depressed clients may use suicide as the ultimate escape from feelings; ensuring safety by protecting the client from self-harm is the priority. Although degree of anger is important, it is not the priority. Assessment of the level of intelligence is unnecessary; clients with a diagnosis of borderline personality disorder are usually of average intelligence. Clients with a diagnosis of borderline personality disorder are more concerned with satisfying their needs than testing reality; they are more concerned about themselves than others or the environment.

A delusional client has refused to eat for the past 24 hours, saying "the food is poisoned." How should the nurse respond? 1. "Why do you think that the food is poisoned?" 2. "You feel worried that someone wants to poison you?" 3. "This feeling is a symptom of your illness. It's not real." 4. "You'll be safe with me. I won't let anyone poison you."

2 Rationale: It is important to help the client focus on feelings, and "You feel worried that someone wants to poison you?" is the only response that helps achieve this goal. Why questions call for a conclusion rather than an exploration of the issue; the client may not have the answer. Although stating that the feeling is a symptom of the client's illness is true, it is not something that the client is ready to understand; also, it is a closed statement. "You'll be safe with me. I won't let anyone poison you" is false reassurance and is not realistic; the client still is concerned about what will happen when the nurse is not there.

How can the nurse best assist a client with an obsessive-compulsive disorder to decrease the use of ritualistic behavior? 1. By providing repetitive activities that require little thought 2. By attempting to limit situations that will worsen the anxiety 3. By getting the client involved in activities that will provide distraction 4. By suggesting that the client perform menial tasks to hide feelings of guilt

2 Rationale: People with high anxiety develop various behaviors to relieve the anxiety; when anxiety is reduced, the need for these obsessive-compulsive actions is reduced. Simple repetitive activities will not be therapeutic for this client and may increase anxiety. Getting the client involved in distracting activities is a temporary action that does not address the feelings that cause anxiety. These individuals do not have a need to hide guilt; their problem relates to anxiety.

During the admission process, a client with symptoms of manic behavior has pressured speech punctuated with profanity. What is the most therapeutic approach for the nurse to use to manage this client's behavior? 1. Explaining in detail the type of behavior allowed in the facility 2. Stating that the use of profanity should stop, because it is inappropriate 3. Interrupting the interview until the client refrains from using profanity 4. Encouraging the client to keep talking while using a nonjudgmental attitude

2 Rationale: Setting limits on acting-out behavior may prevent an escalation of anger that may result in harm to the client or others. Detailed explanations are not helpful, because the client's easy distractibility interferes with understanding. Interrupting the interview without setting limits on the behavior will be ineffective. Clients with pressured speech do not need encouragement to talk. The nurse should be nonjudgmental but must also set limits on inappropriate language and behavior to provide needed structure and feedback.

A nurse is counseling the family of a child with school phobia. What should the parents be taught to do? 1. Accompany the child to the classroom. 2. Return the child to school immediately. 3. Explain to the child why school attendance is necessary. 4. Allow the child to enter the classroom before other children.

2 Rationale: The longer children with school phobia stay out of the classroom, the more difficult it is to get them to return to school, because more fantasies and fears develop. Accompanying the child to the classroom will feed into the child's fear that the phobia is realistic. Explaining to the child why school attendance is necessary is not effective. Allowing the child to enter the classroom before other children will intensify, not ease, the child's fear.

A client with schizophrenia says to the nurse, "I've been here 5 days. There are five players on a basketball team. I like to play the piano." How should the nurse document this cognitive disorder? 1. Word salad 2. Loose association 3. Thought blocking 4. Delusional thinking

2 Rationale: These ideas are not well connected and there is no clear train of thought. This is an example of loose association. Word salad is incoherent expressions containing jumbled words. This client's thoughts are coherent but not connected. Thought blocking occurs when the client loses the train of thinking and ideas are not completed. Each of the client's thoughts is complete but not linked to the next thought. These statements are reality based and not reflective of delusional thinking.

A hospitalized older depressed client tells the nurse that life is no longer worth living. What is the best response by the nurse? 1. "Why do you want to die?" 2. "Are you having thoughts about suicide?" 3. "You must be very depressed to feel that way." 4. "Let's focus on something positive in your life."

2 Rationale; Asking direct questions about suicidal intent helps the client verbalize, because it demonstrates to the client that the topic is one that can be discussed. It also provides essential information needed to plan care. Asking the client the reason for wanting to die is not the priority; the client has already said that life is not worth living and may not be able to elaborate further. Stating that the client must be very depressed is judgmental and may put the client on the defensive and block communication. By moving the focus to finding something positive to talk about, the nurse is avoiding discussing the issue; this statement may block further communication.

When a nurse enters a room to administer an oral medication to an agitated and angry client with schizophrenia, paranoid type, the client shouts, "Get out of here!" What is the most therapeutic response? 1. Stating, "You must take your medicine now." 2. Saying, "I'll be back in a few minutes so we can talk." 3. Explaining why it is necessary to take the medication 4. Withholding the medication before notifying the primary healthcare provider

2 Rationale; Saying, "I'll be back in a few minutes so we can talk" allows the angry client time to regain self-control; announcing a plan to return will ease fears of abandonment or retribution. Staying and insisting that the client take the medication may provoke increased anger and further loss of control. Clients will not accept logical explanations when angry. Alternative nursing interventions should be attempted before withholding the medication and notifying the primary healthcare provider, although these may become necessary.

A nurse is caring for a client with bipolar I disorder. What should the plan of care for this client include? Select all that apply. 1. Touching the client to provide reassurance 2. Providing a structured environment for the client 3. Ensuring that the client's nutritional needs are met 4. Engaging the client in conversation about current affairs 5. Designing activities that require the client to maintain contact with reality

2, 3 Rationale: Structure tends to decrease agitation and anxiety and to increase the client's feelings of security. Whether the individual is experiencing mania or depression, nutritional needs must be met. The hyperactivity associated with mania interferes with the ability to sit still long enough to eat; hyperactivity requires an increase in the intake of calories for the energy expended. Touching can be threatening for many clients and should not be used indiscriminately. Conversations should be kept simple. The client with a bipolar disorder, either depressed or manic phase, may have difficulty following involved conversations about current affairs. Clients with bipolar disorders are in contact with reality, so designing activities that require the client to maintain such contact will serve little purpose.

A 17-year-old client is diagnosed with leukemia. Which statements by the teenager reflect Piaget's cognitive processes associated with adolescence? Select all that apply. 1. "My smoking pot probably caused the leukemia." 2. "I'm going to do my best to fight this awful disease." 3. "Now I can't go to the prom because I have this stupid disease." 4. "I know I got sick because I've been causing a lot of problems at home." 5. "This illness is serious, but with treatment I think I have a chance to get better."

2, 3, 5 Rationale: At 17 years of age the adolescent is in the formal operational stage of cognitive development and therefore able to understand the seriousness of leukemia and the need for treatment. Adolescents also are preoccupied with peer socialization. At 2 to 7 years of age children are in the preoperational stage of cognitive development. They believe that external, unrelated, concrete phenomena cause illness. At 7 to 10 years of age children are in the concrete operational stage of cognitive development. Because of their egocentrism, they believe that they are responsible for situations such as illnesses and are being punished for bad behavior.

When a nurse is admitting an older client to the mental health unit, it is important to identify any signs of dementia. What signs and symptoms denote the presence of dementia of the Alzheimer type? Select all that apply. 1. Ambivalence 2. Forgetfulness 3. Flight of ideas 4. Loose associations 5. Expressive aphasia

2, 5 Rationale: Older clients who have dementia [1] [2] often have short-term memory loss. Clients in whom dementia is developing often have difficulty expressing themselves (expressive aphasia) or understanding the spoken word (receptive aphasia). Clients with the diagnosis of schizophrenia or depression are often indecisive and ambivalent. A client who is experiencing a manic episode of bipolar disorder experiences flight of ideas. Loose associations between thoughts are related to schizophrenia, not dementia.

A nurse is interviewing a client who is dying. Place these client statements in the order that reflects the stages in Kübler-Ross' theory of death and dying. 1. "I've said all my goodbyes, and I am so tired." 2."That lab is always messing up results and making mistakes." 3. "It's heartbreaking that I'll never get to know my grandchildren." 4. "All I really want is to live long enough to see my son graduate from college." 5. "This isn't fair—I played by the rules and now I'm the one who's dying."

2, 5, 4, 3, 1 Rationale: The first phase is denial. The statement blaming the lab ("why me?") reflects denial because the client is assuming that there has been an error in diagnosis. The second phase is anger; the assertion that the situation is not fair ("why me?") reflects anger because the client is upset about the terminal illness when the client engaged in wellness behaviors throughout life. The third phase is bargaining. Expressing a wish to see a son graduate ("yes, me, but") reflects bargaining because the client is expressing a desire for more time to live. The fourth phase is depression. This statement ("yes, me") reflects depression because the client is sad about what will never be. The fifth phase is acceptance. The client's announcement that he or she has said goodbyes and is tired reflects preparation for death.

A nurse becomes aware of an older client's feeling of loneliness when the client states, "I only have a few friends. My daughter lives in another state and couldn't care less whether I live or die. She doesn't even know I'm in the hospital." How should the nurse interpret the client's communication? 1. As a call for help to prevent the client from acting on suicidal thoughts 2. As a manipulative attempt to persuade the nurse to call the daughter 3. As a reflection of depression that is causing feelings of hopelessness 4. As a request for information about social support groups in the community

3 Rationale: This statement provides clues that the client feels no one cares, so there is no reason the client should care. These feelings are common in depression. The clues presented should not lead the nurse to conclude that the client is looking for help to prevent suicidal activities, is attempting to manipulate the nurse, or is looking for information about community social support groups.

A health care provider refers a 52-year-old man to the mental health clinic. The history reveals that the man lost his wife to colon cancer 6 months ago and that since that time he has seen his health care provider seven times with the concern that he has colon cancer. All tests have had negative results. Recently the client stopped seeing friends, dropped his hobbies, and stayed home to rest. Which disorder should the nurse identify as consistent with the client's preoccupation with the fear of having a serious disease? 1. Conversion disorder 2. Somatization disorder 3. Hypochondriac disorder 4. Body dysmorphic disorder

3 Rationale: Preoccupation with fears of getting or having a serious disease is called hypochondriasis. The condition usually exists for 6 months or longer, persists despite negative medical tests and reassurance, and results in social or occupational impairment. Conversion disorder is characterized by the presence of one or more symptoms related to a neurological problem that has no organic cause. Somatization disorder is characterized by the reporting of many physical problems by the client, usually beginning before age 30; physical problems may include pain, gastrointestinal symptoms, sexual or reproductive problems, and at least one symptom that suggests a neurological disorder. Body dysmorphic disorder is characterized by preoccupation with some imagined defect in appearance that causes marked distress and significant impairment in social and occupational function.

A client who has been hallucinating suddenly rises and shouts, "Stop saying that. Who do you think you are?" What is the most therapeutic response by the nurse? 1. Telling the client that ignoring the voices will make them disappear 2. Taking the client to the client's room for a quiet place to think away from other clients 3. Telling the client that the voices are not heard by others, then offering to listen to music together 4. Pointing out to the client the inappropriateness of the behavior in a nonthreatening, nonjudgmental manner

3 Rationale: Telling the client that others don't hear the voices and offering to listen to music together presents the reality of the situation and helps distract the client during a threatening hallucination. Telling the client to simply ignore the voices is not therapeutic. It will be difficult for the client to do this. Taking the client to the client's room encourages withdrawal and isolation and will not stop the hallucination. Pointing out the inappropriateness of the client's behavior will have little effect on it and will not stop the hallucination.

A nurse on a psychiatric unit has been working with a suicidal college student for 2 days. What comment by the student indicates relief from suicidal thinking? 1. "I can be a burden to others." 2. "I feel very alone sometimes." 3. "I plan to go to school next semester." 4. "I don't know whether I can talk about my feelings."

3 Rationale: The suicidal client cannot think about a positive future; therefore focusing on the future indicates improvement. Feeling like a burden to others reflects low self-esteem, which also increases the risk for suicide. Feeling alone reflects a perceived lack of support, which increases the risk for suicide. Not being able to talk about feelings increases the risk for suicide, because the client must be able to verbalize feelings to reduce anxiety, seek help, or engage in therapy.

A nurse is caring for a client who is experiencing a crisis. Which nervous system is primarily responsible for the clinical manifestations that the nurse is likely to identify? 1. Central nervous system 2. Peripheral nervous system 3. Sympathetic nervous system 4. Parasympathetic nervous system

3 Rationale: The sympathetic nervous system reacts to stress by releasing epinephrine, which prepares the body to fight or flee by increasing the heart rate, constricting peripheral vessels, and increasing oxygen supply to muscles. Although the brain responds to stress, it is the sympathetic nervous system that is primarily affected. The sympathetic and parasympathetic nervous systems are both part of the peripheral nervous system; the sympathetic nervous system primarily is affected, and the parasympathetic nervous system does not play a role in the fight-or-flight reaction. The parasympathetic nervous system has an effect opposite that of the sympathetic nervous system.

The ritual of a client with obsessive-compulsive disorder involves washing the hands every 30 minutes. The client becomes anxious and agitated if unable to perform this ritual. What should the nurse in the mental health daycare center do? 1. Lock the door to the bathroom. 2. Keep the client actively involved in projects in the facility. 3. Permit the client to wash hands as frequently as desired. 4. Set a contract with the client limiting the frequency of the ritual.

4 Rationale: Allowing the client to be involved with decision-making promotes a feeling of control. Jointly setting limits on the frequency of the ritual will help prevent injury to the client's skin. A ritual is used as a defense against anxiety. Preventing the client from performing the ritual (locking the door to the bathroom) will increase anxiety. Keeping the client actively involved in projects in the facility is unlikely to help, because rarely can a client with obsessive-compulsive disorder be distracted from a compulsive ritual. If the nurse does not intervene and allows the client to wash the hands as frequently as desired, serious impairment of skin integrity could develop.

A client with a history of a short temper and physically abusive behavior becomes violent and is admitted to the psychiatric service. At the time of admission the client is extremely anxious. What is the priority nursing action? 1. Sitting quietly with the client 2. Encouraging the client to play video games 3. Introducing the client to several other clients 4. Assigning a staff member to supervise the client

4 Rationale: Assigning a staff member to supervise the client will enable the staff member to respond quickly to any escalation in the client's mood or behavior. Sitting quietly with the client may put the nurse at risk, because it may actually make the client more anxious and precipitate violence. The client is too anxious to concentrate on a game or to interact with other people.

A client with major depression is admitted to the hospital. What is the most therapeutic initial nursing intervention? 1. Introducing the client to one other client 2. Requiring participation in therapy sessions 3. Encouraging interaction with others in small groups 4. Conveying an attitude of concern that is not intrusive

4 Rationale: Conveying concern without being intrusive will allow the client to control the pace of development of the nurse-client relationship. Depressed clients are unable to move into relationships with other clients or group situations. It is too early for therapy sessions; the first thing that must be established is a trusting nurse-client relationship.

A client with a history of violence is increasingly agitated. Which immediate nursing intervention will most likely increase the risk of acting-out behavior? 1. Being assertive 2. Responding early 3. Providing choices 4. Teaching relaxation

4 Rationale: Once the client is agitated, teaching will not be effective and may increase the client's anxiety. Teaching relaxation techniques can be done once the client calms down. Being assertive (not aggressive) shows the client that the nurse is confident in handling the situation. This may help reduce the client's anxiety. Responding before agitation escalates makes interventions more likely to be successful. Providing choices may help the client feel less threatened and avoids a power struggle.

An older adult client who is hospitalized for a medical problem has dementia of the Alzheimer type and is no longer able to live alone. The client is to be transferred from the hospital to a long-term care facility. When should the staff begin preparation for the transfer? 1. As soon as the transfer is approved 2. When the client talks about future plans 3. When the primary healthcare provider writes the prescription 4. Immediately after the client's admission to the hospital

4 Rationale: Preparation for discharge to either a private home or a long-term care facility should be started on the day of admission to the hospital; this allows time for physical, intellectual, and emotional preparation. Starting the preparations when the transfer is approved, when the client talks about the future, or when the primary healthcare provider writes the prescription will make the adjustment more difficult than if the client has adequate preparation; the client needs time to understand and accept limitations to help set future goals.

What should the nurse initially plan to do to give clients with histories of long-term alcohol abuse greater responsibility for maintaining sobriety? 1. Confront them about their substance abuse. 2. Administer medications exactly as prescribed. 3. Explain what to expect in detoxification programs. 4. Assist them in adopting more healthful coping patterns.

4 Rationale: The client must learn to develop and use more healthful coping mechanisms if drinking is to be stopped. The responsibility is with the client because the client must do the changing. Although confrontation may be helpful in breaking through denial, it alone does not foster increased responsibility for maintaining sobriety. Medications do not provide the motivation for change; this must come from within the client. Explaining what to expect in detoxification programs will tell the client what to expect but will not instill responsibility for change.

A middle-age client who has lost 20 lb (9.1 kg) over the last 2 months cries easily, sleeps poorly, and refuses to participate in any family or social activities that were previously enjoyed. What is the most important nursing intervention? 1. Providing the client with a high-calorie, high-protein diet 2. Reducing the client's crying episodes by setting firm, consistent limits 3. Assuring the client that usual function will be regained in a short time 4. Allowing the client to externalize feelings, especially anger, in a safe manner

4 Rationale: When a client exhibits adaptations related to depression, the greatest danger is self-inflicted injury when feelings, especially anger, are internalized. There are not enough data to show that the weight loss is the result of malnutrition. The client is unable to regulate crying at this time. Assuring the client that usual function will be regained in a short time is false reassurance and is not supportive of the client's feelings.

The parents of an autistic child begin family therapy with a nurse therapist. The father states that the family members wish to share their religious beliefs with the therapist. What should the nurse do? 1. Limit the father's discussion of religion. 2. Include the mutual discussion of religious beliefs. 3. Invite the family's religious leader to a therapy session. 4. Encourage family discussion of their religion in the sessions.

4 Rationale; If religious beliefs are a family concern, the nurse should allow discussion of the family's thoughts and feelings on the subject; the discussion should be encouraged, not limited. The role of the nurse is to facilitate and listen, not to participate in a mutual discussion about religious beliefs. The religious leader is not part of the family unit and should be invited only if this is requested by the family.