NCLEX Mental Health
A client who was recently paroled as a sex offender is in therapy for pedophilia. The client says, "I've served my sentence and I'm still in therapy, so why does this group have posters of me all over the neighborhood? It has my picture on it and tells all about me." Which would be a therapeutic response by the nurse?
"Are you saying that you understand people are afraid for their children but that you feel you are being unfairly treated?"
An unlicensed assistive personnel (UAP) is assigned to work with the nurse to care for a client who is at risk for suicide. Which statement made by the UAP indicates to the nurse that the UAP understands suicide?
"Discussing suicide with a client is not harmful."
The nurse is caring for a client who is suspected of being dependent on drugs. Which question should be appropriate for the nurse to ask when collecting data from the client regarding drug abuse?
"How much do you use and what effect does it have on you?"
An adolescent who has been reported for drawing sexually explicit scenes in her school textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms?
"I am concerned about you. Are you now or have you ever been abused?"
During a group meeting, a client diagnosed with posttraumatic stress disorder (PTSD) verbalizes difficulty with maintaining realistic behavior. Which response by the nurse would be therapeutic?
"I can see that you are upset about this. Let's talk about this some more."
The nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why don't you just leave me alone?" The nurse should make which therapeutic response to the client?
"I can see that you are upset. I'll be back in a few minutes to see how you are doing."
The nurse working the evening shift is assisting clients in getting ready to go to sleep. A client diagnosed with obsessive-compulsive disorder (OCD) becomes upset and agitated and asks the nurse to sit down and talk. Which response by the nurse would be best at this time?
"I can see that you're upset. I'm willing to listen."
The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response?
"I cannot discuss any client situation with you."
The nurse is providing care to a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response?
"I cannot promise to keep a secret."
The nurse is monitoring a client who is in seclusion. Which statement would indicate that the client is safe to come out of seclusion?
"I don't feel like hurting myself anymore."
The nurse is working with a client who is delusional. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which is the best response by the nurse?
"I don't know about a religious cult. Are you afraid that people are trying to hurt you?"
A hospitalized client who is experiencing delusions and has a diagnosis of schizophrenia says to the nurse, "I know that the doctor is talking to the CIA to get rid of me." Which should be the nurse's best response?
"I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?"
A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is an appropriate response by the nurse?
"I hear what you are saying, but I don't share your belief."
The nurse is collecting data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this-it's private and personal." Which statement by the nurse indicates a therapeutic response?
"I know that some of these questions are difficult for you, but as the nurse, I must legally respect your confidentiality."
The nurse is reviewing the discharge plan with a female teenager with anorexia nervosa and reinforces the importance that the teenager attends a meeting of the local chapter of Anorexia Nervosa and Associated Disorders. Which response by the teenager indicates that she will likely be compliant with this plan?
"I'm going to do whatever it takes to get better."
A client has been hospitalized and has participated in substance abuse therapy group sessions. On discharge, the client has consented to participate in Alcoholics Anonymous (AA) community groups. Which statement by the client best indicates to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use?
"I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people."
The nurse is caring for an older, depressed client whose son was killed in an armed robbery after murdering two people. The client says, "I don't know what I did wrong. His dad died a hero in Vietnam when he was only 2 years old, but he's had everything. When he threw the cat up against the wall to see if it landed on its feet and stole money from me and denied it, his sister covered for him." The nurse plans to make which therapeutic response to the client?
"It seems as if you or your daughter feel regret?"
The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." The nurse should make which appropriate response?
"It sounds as though you are feeling all alone right now."
A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse should be therapeutic?
"It's okay to grieve and be angry with your daughter and anyone else for a time."
The nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." The appropriate response by the nurse is which?
"Our relationship is a therapeutic and helping one."
A client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend and states that he "cannot sing." Which response by the nurse is therapeutic?
"Perhaps you could just enjoy the music without singing."
The nurse is collecting data on a client who is actively hallucinating. Which nursing statement should be therapeutic at this time?
"Sometimes people hear things or voices others can't hear."
A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse should make which therapeutic response to the client?
"Tell me about your difficulty sleeping."
While the nurse is providing care, a client angrily reports to the nurse that the health care provider purposefully provided wrong information about her diagnosis and states, "The doctor lied to me." Which nursing response would likely be a barrier to further communication with the client?
"The health care provider would never lie to you."
The nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates the need for further teaching about this self-help group?
"The leader of this self-help group is the nurse or psychiatrist."
The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which would be a therapeutic response by the nurse?
"What aspects of this situation are the most difficult for you?"
The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which?
"What do you find difficult about this situation?"
A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem to be worth it anymore. Why not just end it all?" Which initial nursing response is appropriate?
"What do you mean by that?"
The nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client?
"What is causing you to become agitated?"
The nurse is collecting data on a client in crisis. Which question should the nurse ask to determine the client's perception of the precipitating event that led to the crisis?
"What leads you to seek help now?"
The nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, the most appropriate question to ask is which?
"What leads you to seek help now?"
A 2-year-old child is a suspected victim of child abuse. The nurse is interviewing the child's parent. Which statement made by the parent indicates a characteristic associated with child abuse?
"When I tell my child to do something once, I don't expect to have to repeat it."
The nurse assists in making a plan of care for a client and is developing goals that will help the client achieve an optimal level of functioning and use resources. When the nurse enters the client's room, the client says to the nurse, "Could you ask the health care provider to let me have a pass for the weekend?" Which nursing response is appropriate to assist the client in achieving the goal that has been set for this client?
"When the health care provider arrives on the unit, I will let her know that you have a question."
While providing one-to-one supervision, a client who attempted suicide tells the nurse, "I can never do anything right. I'm such a loser. It didn't even work when I tried to kill myself." Which is the appropriate nursing response?
"You don't think you can ever do anything right?"
The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?
"You must be feeling all alone at this point."
A client admitted with depression states to the nurse, "My life has been such a failure; nothing I do turns out right." Which response by the nurse would be therapeutic?
"You seem very discouraged. Can you think of anything recently that went as you planned?"
A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?
"You seem very distressed over learning you have asthma."
The nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just weren't around." Which response by the nurse would be appropriate at this time?
"You sound very unhappy. Are you thinking of harming yourself?"
A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse?
"You understand that people fear for their children, but you're feeling unfairly treated?"
A client with lung cancer says to the nurse, "I'm sick and tired of my family telling me not to worry and that a cure will be discovered before I know it." Which response by the nurse is therapeutic?
"You're feeling angry that your family is hoping for a cure?"
A client with depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The nurse should make which therapeutic response to the client?
"You've been feeling like a failure for a while?"
The nurse is caring for a client who is hospitalized because of severe depression. Which statements would be most helpful in assisting this client? Select all that apply.
1. "I notice you are wearing a blue shirt." 2. "Do you have any plans of harming yourself?" 4. "I will sit here with you even if you choose not to talk with me."
The nurse is assessing a client who takes antipsychotic medication for which signs/symptoms that might indicate the development of neuroleptic malignant syndrome? Select all that apply.
1. Diaphoretic 4. Temperature of 104.8° F 5. Blood pressure of 210/130mm Hg
The licensed practical nurse is assisting the registered nurse in admitting a client with an exacerbation of schizophrenia and knows that which signs/symptoms displayed by the client are considered positive symptoms? Select all that apply.
1. Hallucinations 3. Delusions 4. Neologisms
An adolescent client is admitted to the inpatient unit after medical stabilization for an overdose of acetaminophen (Tylenol). The history identifies that her boyfriend broke up with her 2 weeks ago and that she hasn't been eating well, resulting in a loss of 15 pounds. The nurse assists in developing a plan of care that includes which interventions? Select all that apply.
1. Making nutritious snacks available anytime 2. Providing meals on an isolation tray that contains plastic utensils 4. Ensuring that her diet consists of bland, easy-to-digest foods and beverages
A client diagnosed with schizophrenia is experiencing an acute dystonia reaction. Which interventions should the licensed practical nurse (LPN) initiate? Select all that apply.
1. Monitor airway. 2. Notify the registered nurse (RN). 4. Remain with the client to provide support. 6. Administer a prescribed IM antiparkinsonian medication.
Which are appropriate interventions for caring for the client in alcohol withdrawal? Select all that apply.
1. Monitor vital signs. 3. Provide a safe environment. 4. Address hallucinations therapeutically. 6. Provide reality orientation as appropriate.
Which are appropriate interventions for caring for the client in alcohol withdrawal? Select all that apply.
1. Monitor vital signs. 3. Provide a safe environment. 4. Address hallucinations therapeutically. 6. Provide reality orientation as appropriate.
The nurse is caring for a client with depression in the mental health unit who is refusing to take the prescribed oral antidepressant. Which are the nurse's best actions to this client's medication refusal? Select all that apply.
1. Notify the health care provider. 2. Document the refusal of medication. 3. Ask the client why he is refusing the medication.
The nurse is caring for a client with a somatic disorder and knows that which interventions would be most helpful to this client? Select all that apply.
1. Reinforce the client's problem-solving abilities. 4. Assess "secondary gains" that the somatic illness provides the client.
The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply.
1. Restating 2. Listening 4. Maintaining neutral responses 6. Providing acknowledgment and feedback
A client who has terminal cancer has been experiencing a significant increase in pain. However, today the client is no longer complaining of pain but is quiet and isolative. Which types of therapeutic communication should the nurse employ? Select all that apply.
1. Sit by client's bed holding his or her hand. 2. Reminisce with the client and sharing a humorous story that the client enjoys. 3. The nurse asks: "What can I do, that might make you feel more comfortable today?" 5. The nurse asks: "I noticed you grimacing earlier when I walked in your room. Are you in pain?" 6. The nurse states: "It must be very frustrating to be in pain and not be able to get complete relief from your pain."
A woman is brought to the emergency department in a severe state of anxiety after witnessing a devastating car accident that killed two people. Which should the nurse assigned to care for the client do first?
1. Take the client to a quiet room.
The nurse is having a therapeutic discussion with a client and knows that which statements by the client should be immediately reported to the charge nurse? Select all that apply.
2. "I hid my silverware from dinner last night." 5. "I know that by this time tomorrow all my troubles will be over."
The licensed practical nurse is assisting in the admittance of a client who has been involuntarily committed to the behavioral health unit. Which actions by the client before hospitalization led to the commitment? Select all that apply.
2. Client threatened to commit suicide. 3. Client threatened to kidnap his spouse.
The nurse prepares the plan of care for a client with late-stage Alzheimer's disease who resides in a long-term care facility. Which would be priority concerns to include? Select all that apply.
2. Risk for injury 4. Risk for infection 5. Risk for aspiration 6. Impaired verbal communication
While discharge planning for a female teenager with anorexia nervosa, the nurse suggests that the teenager attends a meeting of the local chapter of anorexia nervosa and associated disorders. Which responses by the teenager indicate that she will likely be compliant with this suggestion? Select all that apply.
3. "I'm going to do whatever it takes to get better." 5. "I'll go and participate as much as I can in the group discussions."
A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? Select all that apply.
3. "My boyfriend yells and accuses me of having an affair if I am late after work." 4. "I have bruises all over my body. I am frequently clumsy and fall a lot." 1. "My husband always brings me flowers and apologizes after he hits me."
The nurse caring for a client with schizophrenia prepares to document which symptoms exhibited by the client as negative symptoms? Select all that apply.
3. Avolition 5. Anergia
The nurse caring for a client who has been diagnosed with stage 3 Alzheimer's disease and should expect to observe which behaviors in this client? Select all that apply.
3. Misplacing a valuable object 5. Difficulty coming up with the right word
The nurse is caring for a client who has been diagnosed with a dissociative disorder. Which interventions should the nurse use in providing care for the client? Select all that apply.
3. Request that the client perform undemanding, self-care tasks. 4. Reinforce teaching the client techniques to maintain present reality. 5. Assist the client to reestablish relationships with significant others.
The nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which information is accurate regarding depression and the older client? Select all that apply.
3. Suicide is a frequent cause of death among the older population. 4. Some indications of dementia may actually originate as depression. 5. Depression in an older person is likely to have physical manifestations.
A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which?
4. Evidence of the client's altered and distorted body image
The nurse is collecting data on a client with the diagnosis of anorexia nervosa. Which findings are indicative of anorexia nervosa? Select all that apply.
4. Personality changes 5. Lanugo over the back and extremities 2. A high achiever
The nurse is assigned to care for a client at risk for alcohol withdrawal. The nurse monitors the client, knowing that the early signs of withdrawal will usually develop within which time after cessation or reduction of alcohol intake?
4. Within a few hours
Which client is most likely at risk to become a victim of elder abuse?
A 90-year-old woman with advanced Parkinson's disease
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate?
A client receiving diagnostic tests
The nurse must choose a roommate for a client who is in a state of starvation due to anorexia nervosa. The nurse should avoid choosing which client as a roommate for the client with anorexia nervosa?
A client with pneumonia
A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse initially plans to take which action with this client?
Accept the client as a person and make the client feel safe.
A client has just been admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder (OCD). The nurse observes the client for compulsive behavior that denotes repetition in which?
Actions
A client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has which?
Agoraphobia
A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse should encourage the client to attend which community group?
Alcoholics Anonymous
A client with a diagnosis of a recurrent major depression, exhibiting psychotic features, is admitted to the mental health unit. In an attempt to create a safe environment for the client, the nurse designs a plan of care that deals specifically with which aspect of the client's disorder?
Altered thought processes
The nurse is caring for a client with anorexia nervosa. The nurse planning care for the client recognizes that which manifestation is likely to be present?
Amenorrhea
A client in a manic state emerges from her room. The client is dressed in a low-cut blouse and a miniskirt. She is not wearing underwear and she proceeds to sit on a male client's lap and begins to make sexual remarks and gestures to the male client. The nurse should take which action?
Approach the client quietly, take her to her room, and assist her in getting dressed.
The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for this phase?
Assist in making appropriate referrals.
Treatment that involves pairing a stimulus attractive to the client with an unpleasant event is known as which type of therapy?
Aversion therapy
A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care?
Avoid joking or laughing in the presence of the client.
A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. The nurse should take which action?
Call the nursing supervisor.
A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. The appropriate nursing action is which?
Call the nursing supervisor.
Milieu therapy is prescribed for a client. The nurse understands that this type of therapy can best be described as which?
Client involvement in goal setting
A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse identifies which symptoms or behaviors as requiring immediate intervention?
Constant physical activity and poor oral intake
The nurse is preparing a discharge plan for a client who attempted suicide. The nurse understands that the plan of care should focus on which intervention?
Contracts and immediate available crisis resources
A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which?
Conversion disorder
A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which?
Denial
The nurse working in the long-term care facility understands which concept related to depression in the older client?
Depression in the older client is often undertreated.
The nurse is monitoring a client with a history of opioid abuse for signs of withdrawal. The nurse monitors this client for which signs and symptoms associated with opioid withdrawal?
Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia
The nurse is assisting in developing a plan of care for a paranoid client who experiences religious delusions. Which short-term goal would be most appropriate?
Develops a relationship to help reduce the frequency of the delusions
The nurse notes that a client with acquired immunodeficiency syndrome (AIDS) appears anxious and is reluctant to ask questions. Which action should the nurse take to best address these observations?
Discuss common fears and questions expressed by other clients with the same diagnosis.
A client who has a gastrostomy tube for feeding refuses to participate in the plan of care, will not make eye contact, and does not speak to the family or visitors. The nurse identifies that this client is using which type of coping mechanism?
Distancing
A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a medication that can help people like me quit drinking." Which medication should the nurse explain is available for this purpose?
Disulfiram (Antabuse)
The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response should be therapeutic?
Do you recall needing to be hospitalized because you stopped your medication?"
The nurse is caring for a client with severe depression. Which activity is appropriate for this client?
Drawing
The nurse is assisting in conducting a group therapy session. A client who has shared with the group at a previous session that she isolates herself when she feels depressed, suddenly gets up to leave. Which nursing action is appropriate?
Encourage the client to stay and ask the client what she is feeling.
The nurse is assigned to assist in the care of a client with obsessive-compulsive disorder (OCD). The nurse should place first priority on which action when planning care for this client?
Establish a trusting nurse-client relationship.
A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which?
Evidence of the client's altered and distorted body image
When caring for a client who has been raped, which intervention should the nurse implement during the examination?
Explaining procedures to be completed and why the procedures are necessary
The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which observation is indicative of the signs/symptoms associated with withdrawal from opioids?
Fever, yawning, irritability, diaphoresis, and diarrhea
The nurse is preparing a care plan for the client with obsessive-compulsive disorder (OCD). The nurse should focus on which as the primary means to accomplish work with this client?
Goals and objectives
Which is the best rationale for using group therapy as an accepted way of treatment of clients in the milieu?
Group therapy provides a social mechanism in which a client can relate to peers and validate thoughts and feelings in a realistic environment.
A woman is admitted to an inpatient psychiatric unit with the diagnosis of anorexia nervosa. A behavior therapy approach is used as part of her treatment plan. Which is the purpose of the behavior therapy approach?
Help the client identify and examine dysfunctional thoughts and beliefs.
The nurse is assisting in admitting a client with schizophrenia to an acute-care inpatient psychiatric unit from the emergency department; however, the client refuses admission. Which intervention should the nurse implement?
Help the client with problem solving.
The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which?
Hypertension, disorientation, hallucinations
A client who was admitted to the mental health unit 1 month ago with agoraphobia is cooperative, sharing with peers, and makes appropriate suggestions during group discussions. The nurse concludes that this client's behavior is most consistent with which behavior?
Improvement
The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find which sign/symptoms of lithium toxicity associated with this level? Select all that apply.
Incoordination 4. Mental confusion 5. Muscle hyperirritability
A client with Alzheimer's disease became very agitated when a group of children came to sing and dance at a long-term care facility. The nurse should use which piece of information when approaching the client about this behavior?
Individuals with Alzheimer's disease have difficulty tolerating excess stimulation and changes in routine.
The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis?
Inquiring about the client's feelings that may affect coping
The nurse is caring for a client who was recently admitted for anorexia nervosa. Upon entering the client's room, the nurse finds the client in the middle of a series of sets of rapid sit-ups. Which action should the nurse take?
Interrupt the client and offer to take her for a walk.
The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate?
Interrupt the client and offer to take her for a walk.
A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma that occurred 6 weeks ago. The nurse develops a plan of care, knowing which action is the priority?
Look for organic causes of the paralysis.
The nurse is caring for a client who verbalizes a need to increase her self-esteem. Which action should the nurse plan to assist the client in achieving the goal of gaining self-esteem?
Maintain a well-groomed appearance.
The nurse is caring for a client with a diagnosis of agoraphobia. Which behaviors exhibited by the client would support this diagnosis?
Makes excuses for not leaving the house
A client tells the nurse that he is feeling out of control. The nurse observes that the client is pacing back and forth. Which approach by the nurse is appropriate to maintain a safe environment?
Move the client to a quiet room and talk about his feelings.
The nursing student is developing a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which incorrect intervention in the plan?
Observe for excessive exercise.
A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's altered nutrition related to poor nutritional intake. Which nursing intervention related to altered nutrition should be the initial choice?
Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.
The day nurses in a psychiatric unit are receiving report from the night shift. During report, a client approaches the nurses' station, becomes very loud and angry, and demands to be seen by the health care provider immediately. Which nursing intervention is appropriate?
Offer to assist the client to an examination room until the health care provider is notified.
An intoxicated client is brought to the emergency department by local police. The client is told that the health care provider (HCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the HCP immediately. The nurse assisting to care for the client should plan for which appropriate nursing intervention?
Offer to take the client to an examination room until he or she can be treated.
The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?
Open-ended questions and silence
The nurse is assigned to care for a client being admitted to the nursing unit from the emergency department who attempted suicide by ingesting several sleeping pills. The nurse implements which priority action when the client arrives to the unit?
Place the client on one-to-one suicide precautions.
After 5 days in the psychiatric unit, a manic client is able to tolerate short periods in the dayroom. The nurse overhears the client telling another client that he is a journalist posing as a client in order to write an article for a magazine. Which response is the nurse's best action?
Privately confront the client with reality.
The nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. The nurse determines that obesity for this client most likely represents which?
Protection from the risk of intimacy
A mental health nurse is assigned to care for a client with a diagnosis of schizophrenia, acute phase. The nurse should use which approach when planning care for this client?
Provide assistance with grooming and nutrition until the client's thinking is cleared.
The nurse is assigned to care for a client who is suicidal. Which nursing intervention is appropriate for this client?
Provide authority, action, and participation.
The nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines which action is the immediate priority of care?
Provide safety for both the client and other clients on the unit.
The nurse reviews the treatment prescribed for a client with a mental health disorder. The nurse understands that a form of psychotherapy in which the client enacts situations that are of emotional significance is identified by which term?
Psychodrama
The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which?
Psychomotor retardation and side effects of medication
A client in a manic state emerges from her room. She is topless and is making sexual remarks and gestures toward staff and peers. Which is an appropriate nursing action?
Quietly approach the client, escort her to her room, and assist her in getting dressed.
A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that involves which?
Reexperiencing recollections of the trauma
A client is admitted to the psychiatric unit following a serious suicidal attempt by a drug overdose. Which action should the nurse implement?
Remain with the client at all times.
A client comes to the emergency department following an assault and is extremely agitated, trembling, and hyperventilating. Which initial nursing action is appropriate?
Remain with the client until the anxiety decreases.
The nurse is assessing a newly admitted client recently diagnosed with depression. Which data best supports that the client is at risk for self-harm?
Reported hopelessness
A client is scheduled to have electroconvulsive therapy (ECT). Which problem should the nurse include in the plan as a priority?
Risk for aspiration
A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection, the nurse notes no evidence of dehydration and malnutrition at this time. The nurse should immediately plan to address the client's need for which?
Safety and security
A client is diagnosed with catatonic stupor. The client is lying on the bed, hidden under the sheets, with her body pulled into a fetal position. The nurse should take which appropriate action?
Sit beside the client in silence with occasional open-ended questions.
The nurse is gathering data from a client with a phobia. The client tells the nurse that he consistently avoids attending community functions because he fears that he will be asked to speak publicly to the members. On the basis of this information, the nurse determines that the client is experiencing which problem?
Social phobia
A client newly admitted to the mental health unit describes a recent history of emotional turmoil. The client exhibits physical symptoms and has some loss of physical functioning. The nurse determines that this client is exhibiting signs compatible with which?
Somatization disorder
A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathology after a lengthy workup. In planning care for this client, it is important that the nurse understand that the client is suffering from which condition?
Somatization disorder
A client who attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, should take which action?
Stay with the client at all times.
Which nursing approach is important when administering an antianxiety agent to a client with acute severe anxiety?
Stay with the client until the medication becomes effective.
The nurse is assisting in conducting a group therapy session, and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which?
Suggest that the client stop talking and try listening to others.
An adolescent is returning home after an acute psychiatric hospitalization following a suicide attempt. Which action would be least effective in preparing the client to return to a safe and effective care environment?
Suggest that the mother's boyfriend move out of the home.
The nurse in the psychiatric unit is reviewing the records of the clients admitted to the nursing unit. A client with a history of violent behavior approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the client was voluntarily admitted to the psychiatric unit. Which is the appropriate nursing action?
Tell the client that the health care provider will be contacted regarding discharge.
The nurse having strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is likely to react to a disagreement with this fellow employee by which action?
Telling a friend that this employee hates her
The nurse is monitoring a client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client?
The client asks to meet with a lawyer to take care of unfinished business.
Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?
The client gives away a DVD and a cherished autographed picture of the performer.
The nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse makes which determination?
The client has the right to demand and obtain release from the hospital.
A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior?
The client is at increased risk for suicide.
A mental health nurse on the evening shift is receiving report about a client who was admitted to the nursing unit. The nurse is told that the client was admitted by involuntary status. Based on this type of admission, the nurse would expect which statement is an aspect of the client's care?
The client is in need of psychiatric treatment.
A client in the mental health unit engages in repeated hand washing throughout the day. The nurse understands that these repetitive behaviors develop for which reason?
The client is unconsciously attempting to control unpleasant thoughts or feelings.
A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, the nurse expects which?
The client presents a harm to self.
The nurse is collecting data from a client who has recently been violently raped. Which data indicates that the client is experiencing rape-trauma syndrome?
The client reports nightmares involving being stalked when alone at night.
A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the night before ECT treatment should include which intervention?
The client shampoos and dries the hair, freeing it of all hair spray and creams.
The nurse reviews the plan of care for a suicidal client admitted to the hospital. The nurse notes documentation of the client's loss of a spouse, which occurred several years ago. The client progresses well and is approaching discharge. Which is an appropriate goal for this client's care?
The client verbalizes stages of grief and plans to attend a community grief group.
A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse describes the components of this form of therapy to the client and reinforces which client instruction?
The client will be introduced to short periods of exposure to the phobic object while in a relaxed state.
The nurse is working with a victim of rape in a clinic setting and assists in developing a plan of care for the client. Which is an inappropriate short-term initial goal?
The client will resolve feelings of fear and anxiety related to the rape trauma.
A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively. Which is the least realistic goal for this client?
The client will stop blaming himself for the lack of insurance.
The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the data obtained, the nurse should identify which as a priority concern?
The client's report of self-destructive thoughts
The nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse should determine that this type of crisis could be caused by which?
The death of a loved one
The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse understands that these types of delusions are characteristic of which?
The false belief that one is being singled out for harm by others
A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." In helping the mother prepare for her daughter's discharge, the nurse should suggest which?
The mother should restrict the amount of chocolate and caffeine products in the home.
The nurse is assisting in preparing a plan of care for the client who will be seen in the mental health clinic for the first time. In preparing for the orientation phase of the therapeutic relationship, the nurse suggests addressing which issue?
The parameters of the relationship
A client with a history of depression and several suicide attempts is admitted to the mental health unit reporting severe suicidal thoughts. The nurse should focus the initial data collection on which information?
The presence of existing suicidal thoughts
An agoraphobic client has been diagnosed with major depression. The nurse notes that the client is not eating adequately and at times refuses to eat. To meet the client's nutritional needs, the nurse plans which action?
To provide small frequent meals
A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which?
Use a night light and turn off the television.
The nurse employed in a mental health unit who cares for suicidal clients is reviewing the work schedule. The nurse expects to note in the schedule that additional precautions related to safety to the clients will be provided at which times?
Weekends
A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which?
Weight loss
A furiously angry and aggressive client was put in restraints and was told that the restraints would be removed once the client regained control. The nurse appropriately removes the restraints when which action occurs?
When no acts of aggression are observed within 1 hour after release of two extremity restraints
The nurse is assigned to care for a client at risk for alcohol withdrawal. The nurse monitors the client, knowing that the early signs of withdrawal will usually develop within which time after cessation or reduction of alcohol intake?
Within a few hours