NCLEX-Psych

A client admitted to the inpatient mental health unit asks if mail can be received from family. Which statement by the nurse indicates adequate understanding of client rights? 1. Clients can receive and send mail, but staff must check for hazards. 2. Clients are not allowed to receive mail while hospitalized. 3. Receiving mail from family is not encouraged. 4. Clients are allowed to send or receive mail after the first 72 hours after admission.

1. Correct: Clients are allowed to send and receive mail. Mail must be checked for hazards to protect the client and the safety of others on the unit.

A young adult diagnosed with schizophrenia is admitted to the crisis center with exacerbation of psychotic behaviors. The client responds well to a medication regime of chlorpromazine three times daily. The nurse is reviewing discharge instructions and knows teaching was successful when the client makes what statements? Select all that apply 1. "This medication will help me control my behavior." 2. "I should take this medication only if I feel anxious." 3. "I need to have blood levels checked periodically." 4. "My medication will eventually cure my disorder." 5. "I must apply sunscreen and wear a hat if outside."

1., & 5. CORRECT: Chlorpromazine is an antipsychotic medication used to control psychotic or hyperactive behaviors such as those noted in schizophrenia and attention deficit hyperactivity disorder (ADHD). If the medication regime is followed consistently, psychotic behaviors can be minimized. However, chlorpromazine also sensitizes the skin, making the client susceptible to sunburn even on cloudy days. Using sunscreen is vital at all times.

A client admitted in the manic phase of bipolar disorder approaches the nursing station in the middle of the night, demanding the therapist be called immediately. What response by the nurse is appropriate? 1. "Calm down first, and then I will call your therapist." 2. "It's against the rules to call in the middle of the night." 3. "You must be distressed to want to talk at this late hour." 4. "That's a valid request, but it must wait until morning."

3. CORRECT: Regardless of the client's request, the nurse's response should focus on the client's feelings. Rather than reciting the rules or why the phone call cannot be placed, this therapeutic acknowledgement by the nurse clearly addresses the client's emotional state.

A client with psychosis, tells another client, "You are so adorabogalishus." Which form of thought process should the nurse document this client as having? 1. Magical thinking 2. Tangentiality 3. Neologism 4. Perseveration

3. Correct: The psychotic person invents new words, or neologisms, that are meaningless to others but have symbolic meaning to the psychotic person. Remember, do not use the invented word. "Adorabogalishus" is not a real word.

The nurse is discussing information on adolescent obesity with parents of high-school students. What statement by the nurse is most comprehensive regarding obesity among teens? 1. Obesity among teens is often accompanied by psychologic issues like poor self-esteem. 2. Weight issues among teens are often due to excess eating out of boredom or stress. 3. Adolescent obesity is usually an inability to recognize signals of hunger or satiety. 4. Undiagnosed problems of the thyroid or pituitary contribute to teen obesity.

3. Correct: While all the options could be true in some cases, the most accurate and comprehensive basis for obesity is an individual's failure to recognize, or acknowledge, signals of hunger or satiety. Neural circuitry, along with specific body hormones, drives sensations of hunger and feeling satisfied. Adolescents experience fluctuating hormones, physical changes and emotional adjustments which can disrupt body functions, including recognition of brain signals.

The client with mania has repeatedly interrupted group session with the counselor. The client explains that they already know this information about family roles and paces around the room. What should the nurse do at this time? 1. Ask the client to take a walk with you and make another pot of coffee. 2. Ask the client to reflect on their behavior to determine if it is appropriate. 3. Ask the group to tell the client how they feel when they are interrupted. 4. Tell the client to perform jumping jacks and count out loud.

1. Correct: Yes, get them away from the group and do something purposeful. Purposeful activities help the client use energy and focus on something. Distractibility is the nurse's most effective tool.

A distraught client arrives at a mental health crisis center following a house fire that also took the life of a young family member. The nurse knows what action is most important when initiating crisis intervention for this client? 1. Assist the client to verbalize feelings of grief. 2. Assess client for any suicidal behaviors. 3. Admit client to general mental health unit. 4. Assign client to a grief counseling group. Rationale Strategies Let's Talk

2. Correct: Client safety is always the nurse's priority concern where no other life threatening issues exist. A distraught client in crisis from such overwhelming events does not always think or act clearly. The loss of home combined with the death of a family member places the client at potential risk for suicide. Because the client has presented to the mental health crisis center, the nurse must assume the worst and assess for unexpected responses.

The nurse manager of an Alzheimer's unit as completed inservice education to new nursing staff regarding guidelines for dealing with dementia. Which identified guidelines by the new nursing staff indicates to the nurse manager that education was successful? 1. Use a firm touch to guide the client to a different location when needed. 2. Be persistent when getting the client to do something. 3. Provide simple directions using gestures or pictures. 4. Do not argue with the client. 5. Play memory games to decrease dementia. 6. Require participation in daily activities.

3., & 4. Correct: When a person is confused and has dementia, we need to communicate in a simple manner. Provide simple directions or instructions, short sentences, and gestures. Use pictures. Do not give instructions on multiple things. Do not argue, criticize, or correct the client. This can increase anxiety, agitation, and anger.

The nurse is preparing to initiate postmortem care. Which postmortem care interventions would the nurse implement? 1. Identify the client by the name on the client's armband. 2. Remove tubes and indwelling lines after cleansing the body. 3. Insert the dentures after the family has viewed the body. 4. Maintain body preparation according to the client's religious beliefs.

4. Correct: Care of the body after death should be reflective of the client's personal, religious, or cultural practices.

Which type of comment should the nurse expect from a client exhibiting clang associations? 1. Concrete explanations for abstract ideas 2. Reporting very small details when explaining something 3. Comments that are illogically associated 4. Use of rhyming words when talking

4. Correct: The client may use rhyming words, such as dog, bog, cog, jog. It is the meaningless rhyming of words, often in a forceful manner.

A school nurse is planning a lesson on inhalant abuse for a high school health class. Which information does the nurse need to include? 1. Substances used for inhaling include lighter fluid, spray paint, and airplane glue. 2. Inhalants are absorbed through the lungs and cause central nervous system depression rapidly. 3. Although inhaling can make a person very ill, death is highly unlikely. 4. Inhaling substances can cause abdominal pain, lethargy, and renal failure. 5. Inhalants cause the heart to beat slowly.

1, 2, & 4 Correct: Products such as glues, nail polish remover, lighter fluid, spray paints, airplane glue, deodorant and hair sprays, whipped cream canisters, and cleaning fluids are widely available. Many young people inhale the vapors from these sources in search of quick intoxication without being aware that using inhalants, even once, can have serious health consequences. Inhaled chemicals are absorbed rapidly into the bloodstream through the lungs and are quickly distributed to the brain and other organs. Within seconds of inhalation, the user experiences intoxication along with other effects similar to those produced by alcohol. Alcohol-like effects may include slurred speech; the inability to coordinate movements; euphoria; and dizziness. Inhalants also are highly toxic to other organs. It causes abdominal pain, and vomiting. Chronic exposure can produce significant damage to the heart, lungs, liver, and kidneyIn addition, users may experience lightheadedness, hallucinations, and delusions. This information needs to be included in a teaching plan on inhalant abuse. All of these statements are correct and need to be included in a teaching plan on inhalant abuse.

A client on the in-patient psychiatric unit was found to have lacerations on the wrist when the nurse made rounds. Which change in routine on the unit is most likely to prevent such an event from occurring in the future? 1. During the end-of-shift report, assign specific staff to check on each client. 2. Place newly admitted clients close to the nursing station. 3. Monitor level of suicide precaution needed on each client daily. 4. Ask clients to check on each other throughout the shift.

1. Correct: Assigning specific staff to perform client checks during the shift will assure that the clients, that the staff are concerned about their welfare. In addition, it assures that someone is specifically monitoring the client each shift, therefore, promoting the clients right to a safe environment. Client safety is a priority in Maslow's Hierarchy of Needs. The nurses will play a key role in reducing these self-harming behaviors through recognition of the problem, being alert to risk factors when assessing the client, and ultimately guiding the client into more acceptable outlets for stress, anxiety, anger, low-self esteem, or other related causes.

A nurse observes a psychiatric client sitting alone. The client is talking, but occasionally stops and leans to the side as if listening to someone. The client then laughs. What is this client most likely experiencing? 1. Auditory hallucinations 2. Delusions 3. Catatonic excitement 4. Anergia

1. Correct: Auditory hallucinations are false sensory perceptions of sound not associated with real external stimuli. When the client begins to respond to a stimuli that is not visible to the nurse, this is a hallucination.

A client with schizophrenic disorder believes that all of their organs have been replaced and is discussing this belief with others. What would be the most appropriate nursing action? 1. Encourage the client to focus on reality-based issues. 2. Allow the client to continue to talk about the delusions. 3. Ask the client to explain the meaning behind what is being said. 4. Ask the client to take a deep breath to relax.

1. Correct: Get them out of the fantasy and into the real world.

A teenage client asks the nurse, "Do you think I should tell my parents about my sexuality?" What is the nurse's best response? 1. "What do you think you should do?" 2. "Absolutely, I think you should tell your parents." 3. "Don't you think your parents have the right to know about your sexuality?" 4. "I do not think now is the right time to tell your parents. Wait until you are 21."

1. Correct: It is better to say "What do you think you should do?" This helps the client reflect on options and does not have the nurse tell the client what to do. It is much more therapeutic to help the client make the decision for themselves, instead of the nurse. This prevents any biases from impacting the outcome.

The nurse is caring for a client in the outpatient mental health clinic. The client recounts several incidences of spousal abuse. The client says to the nurse, "I know that he loves me. Sometimes I can be quite irritating." Which response is most appropriate by the nurse? 1. "You are not responsible for the abuse." 2. "Sometimes we can irritate our spouses." 3. "The worst is over now." 4. "You should think about leaving him."

1. Correct: The perpetrator is responsible for his/her own actions, but the abused partner may take responsibility or make excuses for them. This mindset needs to be clarified and corrected to prevent further abuse and keep the client safe.

The nurse routinely screens injury victims for the possibility of intimate partner violence (IPV). Which statement correctly supports the nurse's action? 1. Victims of abuse are likely to report injuries and causes that do not fit the normal profile. 2. IPV is not routinely seen in the upper socioeconomic level. 3. All women should be screened, but men are not routinely screened. 4. Only victims who enter the emergency department alone should be screened for IPV.

1. Correct: Victims of abuse most often report causes of injuries that don't fit with the type of injury observed. For example, a victim may report that a bruised eye came from "running into" a door. The victim may feel the abuse is a personal incident or is afraid of the abuser.

The schizophrenic client tells the nurse, "I am Jesus, and I am here to save the world!" The client is reading from the Bible and warning others of hell and damnation. The other clients on the unit are upset and several are beginning to cry. What nursing intervention is most appropriate? 1. Set verbal limits and have the client return to assigned room. 2. Explain to the client that not all people are Christians. 3. Remove the Bible from the client and explain that the client is not Jesus. 4. Ask the client to share with the group how the client is Jesus.

1. Correct: Yes, the nurse must set limits. This is disrupting others and so the client needs to be redirected to their room for a cool down and then another activity shortly thereafter. This client is experiencing delusions of grandeur, which are not reality based, and require intervention that does not reinforce the behavior.

A client states, "I have not had a drink for 24 hours and I am beginning to feel anxious". What additional signs/symptoms would indicate to the nurse that the client is in the early phase of alcohol withdrawal? Select all that apply 1. Agitation 2. Insomnia 3. Course tremors 4. Visual hallucinations 5. Confabulation 6. Tachycardia

1., 2., 3., & 6. Correct: The earliest signs of alcohol withdrawal are anxiety, agitation, insomnia, and tremors. Tachycardia of 120-140 /min persists throughout withdrawal.

The nurse is caring for a client hospitalized with dissociative amnesia. Which nursing interventions are appropriate for this client? Select all that apply 1. Obtain client likes and dislikes from family members. 2. Expose the client with data regarding the forgotten past. 3. Expose client to stimuli that was a happy memory of the past. 4. Hypnotize the client to help restoration of memory. 5. Ensure client safety.

1., 3. & 5. Correct: Considering likes and dislikes may help the client to remember. Using information to expose the client to stimuli that were happy memories may help the client remember. The client's disorder may lead to inattention to safety. Think safety first!

A client of Islamic faith has died and the family wishes to uphold the basic Islamic beliefs for end of life care. What intervention would be appropriate at this time? 1. Upon death, close the eyelids and mouth and pull a covering over the body. 2. Begin necessary preparations for the body to be cremated as soon as possible. 3. Move the body immediately to the morgue for transport to funeral home. 4. Allow someone in the family or mosque to bathe and wrap body in white cloth. 5. Stand quietly or provide privacy as final prayers are offered by family. 6. Place the head of the deceased facing Mecca.

1., 4., 5., and 6. Correct: Based on basic beliefs of the Islamic faith, upon death, the eyes and mouth should be closed. The body should initially be covered with a sheet or similar covering. A practice known as the ghusl is performed which involves the washing of the deceased person's body. This is typically done by an adult family member of the same sex of the deceased, and then the body is enshrouded (wrapped), typically in plain, white cloth. The nurse should show respect to the family by either providing quiet presence as final prayers are offered or by allowing the family to have privacy during this final time with their family member who has died. A practice that may be performed before and/or after the time of death is positioning the head so that it faces Mecca. This may involve moving the bed to where the head faces Mecca or it may involve turning the head to the right side.

Which interventions are appropriate for the nurse to identify for a client admitted to the psychiatric unit for management of anorexia nervosa? Select all that apply 1. Weigh daily. 2. Allow only 20 minutes of exercise daily. 3. Allow the client to bargain for privileges as long as the client eats. 4. Stay with the client during the established time for meals. 5. Maintain visual observation for 1 hour following meals.

1.,4. & 5. Correct: Weigh daily, immediately upon rising and following morning void, using same scale and clothes if possible. The established time for meals is usually 30 minutes. This takes the focus off of food and eating and provides the client with attention and reinforcement. The hour following meals may be used to discard food stashed from tray or to engage in self-induced vomiting.

A client diagnosed with obsessive compulsive disorder has multiple personal care rituals. Which of the client's routines is most concerning to the nurse? 1. Knocks on each hallway door ten times. 2. Flosses teeth five times after each meal. 3. Washes hands three times before a meal. 4. Brushes hair vigorously morning and night.

2. CORRECT: When determining the impact of a client's ritual, the nurse must decide if that routine could cause harm to the client. While each of these routines may be concerning, flossing teeth five times after every meal could lead to gum erosion as well as small cuts in gum tissue. Such aggressive gum care might lead to mouth, or throat infections.

A client is undergoing outpatient psychiatric treatment for somatization disorder. Prior to the beginning of group therapy, the client tells the nurse, "I keep having headaches that are killing me! This has never happened to me before." What is the nurse's best response to this client? 1. You need to sit down, because we need to start the group session now. 2. I will notify the primary healthcare provider about your headaches, after the group session. 3. I guess we can discuss your pain now. Group therapy will have to start later. 4. Your headaches are not real, so ignore them. Go on into therapy so we can start.

2. Correct: Initially, the nurse would fulfill the client's urgent dependency needs, but gradually withdraw attention to physical symptoms. Minimize time given to response to physical complaints. Gradual withdrawal of positive reinforcement will discourage repetition of maladaptive behavior. However, all new symptoms should be reported to ensure physician assessment of the complaint.

A traumatized soldier goes to the infirmary after being told he almost died in a gun battle. He tells the nurse, "I do not remember any of the details of this event. What is wrong with me?" What is the nurse's best response? 1. "I understand you are upset, but you will have to go back to your unit sooner or later." 2. "You are repressing this event because it was frightening and painful for you." 3. "In my professional opinion, you are trying to undo what happened in the battle." 4. "You are splitting from the bad you, so that the good you survives."

2. Correct: Repression is the unconscious blocking from awareness an event or memory of something that is threatening or painful. It is the mind's way of forgetting or experiencing temporary amnesia until it can cope with an overwhelming circumstance. The nurse's response is concise and honest for a client that needs a trusting therapeutic relationship after a traumatic event.

A client receiving electro-convulsive therapy (ECT) tells the nurse, "I don't know if I can take another treatment." What is the nurse's best response? 1. "Remember to focus on the fact that you will be fine after you complete all of your treatments." 2. "The therapy must be difficult for you at times. How do you feel about your progress at this point?" 3. "Hang in there. It's for your own good and times will get better." 4. "What makes you say that? You know it will make you well."

2. Correct: The correct answer allows the client to continue discussing feelings and redirects the client to thoughts of progress and effectiveness of the treatment. Acknowledge the client's feelings and then asking an open-ended question are both appropriate a therapeutic communication techniques.

A client diagnosed with Alzheimer's disease becomes agitated and combative when the nurse approaches to perform a shift assessment. What would be the most appropriate first action for the nurse to take? 1. Obtain assistance to restrain the client. 2. Talk quietly to the client. 3. Administer haloperidol. 4. Leave until the family can calm the client down.

2. Correct: The nurse needs to present a calm manner and speak quietly to the client. This will convey trust and decrease tension and stress in the client.

A new nurse is anxious about being assigned to a a client with violent episodes. Which statement by the charge nurse would address the new nurse's anxiety? 1. "What you really mean is that you fear a client with violent episodes." 2. "Though it is difficult, the staff needs to remain relaxed, but conscious of the client's violent episodes." 3. "I will instruct the staff to monitor the client's behavior for any signs of violent behavior." 4. "You attended an in-service during orientation on dealing with the client with violent behavior."

2. Correct: This response focuses both on the client's and the staff's response to the client. This is an example of the therapeutic communication of restating. The safety of the client, other clients, and the health care team is also a priority. The aggression by the client may be physical, verbal or both. The nurse should remain calm and firm. This approach will assist the client to return to their pre-crisis state.

The nurse has been working with an attractive teenage girl regarding appropriate nutrition. Which statement by the teenager would support a disturbed body image and the need for education on adequate nutrition? Select all that apply 1. "I am happy my weight is within normal limits. " 2. "I can never exercise enough to lose those saddle bags." 3. "I can always work a little harder on school work and hobbies." 4. "I try to eat only two meals a day to keep my weight down." 5. "I have been trying to include more fruits and vegetables in my diet."

2., 3. & 4. Correct: Compulsive exercising may indicate an eating disorder or a risk for developing one. Perfectionism in school, sports, and hobbies may indicate low self-esteem, which is reflected in eating disorders. Compulsive adherence to routines for weight loss or control may indicate a risk for developing an eating disorder.

The client shares that her husband died 2 months ago. She stays at home at least 3 times per week and cries most of the day. Which interventions for dealing with loss would the nurse initiate? 1. Resume previous social activities right away. 2. Establish a structure of daily activities. 3. Reinforce that dreaming about the loved one is positive. 4. Recommend immediate professional assistance. 5. Encourage communicating feelings during grief process.

2., 3., & 5 Correct: Organizing specific daily activities will give the client a sense of control of their lives. This action will assist the client through the day and promotes self-confidence. Dreaming about the deceased is a symptom of the normal grief process. The client is compensating for the loss by experiencing dreams that include her husband. The stages of grief do not proceed in a systematic process. The client may stay in one stage for a while, skip a stage, or begin the stages again from the beginning. The client should express their feeling as they move through the grief stages. Grief is an individualized process.

The nurse is working with the interdisciplinary team in developing a plan of care focused on weight gain for an anorexic client. What intervention would be ineffective for reaching that outcome? 1. Refrain from being critical of client during meals. 2. Permit client to make own food selections on menu. 3. Reward the client with private time for a meal completely eaten. 4. Provide positive reinforcement for each pound gained.

3. CORRECT: Anorexic clients believe they are grossly overweight, regardless of their current physical appearance. Therefore, the individual will attempt to get rid of food ingested at a meal by any means necessary, including aggressive exercise and induced vomiting. Rewarding the client time alone would NOT be effective in reaching the goal of weight gain.

A psychiatric nurse is completing an assessment on an elderly client being started on a tricyclic antidepressant. The nurse is aware the most crucial aspect of this assessment is evaluating what body system? 1. Endocrine 2. Nervous 3. Circulatory 4. Digestive

3. CORRECT: Tricyclic antidepressants can cause arrhythmias, changes in heart rate, and blood pressure fluctuations including orthostatic hypotension. A client's cardiovascular status should always be evaluated prior to starting this category of medication to determine the presence of pre-existing cardiac conditions.

The school nurse has been observing a 13 year-old student during the past few months as the student has steadily lost weight. Which assessment finding would be the best indication of the beginning of an eating disorder? 1. Clothing size has decreased by 2 sizes. 2. Student eats most meals with peers. 3. Client reports a fear of gaining weight. 4. Diet consists mostly of fruit or raw vegetables.

3. Correct: An adolescent reporting a fear of gaining weight may indicate the beginning of an eating disorder. This is the best indicator of an eating disorder.

The nurse discovers that a client diagnosed with severe depression formerly taught art classes at a local school. The nurse offers to obtain needed supplies if the client would instruct a few interested clients on simple painting techniques. The nurse is aware this type of intervention may help the client achieve what outcome? 1. Distract client from depressive thoughts of hopelessness. 2. Encourage client to begin communicating with others. 3. Utilize client's own strengths to increase self-esteem. 4. Establish the trusting nurse/client relationship.

3. Correct: Depressed clients often feel hopelessness, failing to recognize personal value or purpose. The nurse is drawing attention to the client's personal strengths and abilities to help achieve the goal of recognizing self-worth and improving self-esteem.

The home health nurse is caring for an elderly client who lives with an adult child. The client's child is divorced, works full-time, and is responsible for caring for two young children. Recently, the client has become incontinent of urine. Which stressor on the caregiver may increase the risk for abuse of this elderly client? 1. Care of young children 2. Being divorced 3. Recent increased care demands 4. Loneliness of the adult child

3. Correct: Recently increased care demands place a greater strain on the time and money required to provide care. The changing level of demands may increase the risk of abus

A young adult client frequently engages in high risk behaviors, including driving at high speeds, using alcohol in excess, and engaging in high risk sexual behaviors. Which problem is priority for the nurse to assess? 1. Antisocial personality traits causing the disregard for life. 2. Impaired judgment caused by arrested psychological maturation. 3. Unconscious suicidal thoughts. 4. Unhealthy grieving.

3. Correct: Since all the behaviors could lead to death, these are considered indicators of self-destructive behaviors. The resulting conflict of weakness and strengths can produce negative emotions. These emotions can be manifested in risky behaviors.

The nurse is working on an in-patient psychiatric unit. The nursing care plan includes teaching a client about assertiveness. The client has a long history of being manipulated by the employer and spouse. What is the best rationale for including assertiveness training in this client's treatment plan? 1. All clients should have assertiveness skills. 2. The client has low self-esteem. 3. The client is being taught self-advocacy. 4. No client deserves to be manipulated by an employer.

3. Correct: The client is being taught assertiveness and thus self-advocacy is learning to speak up for yourself and one's needs. The nursing role includes advocacy. This client will be discharged soon and needs improved skills in assertiveness for the word place and home environment.

A hospitalized American Indian elder is actively dying and is surrounded by a large group of family members. The client's spiritual beliefs include burning a tiny amount of incense while chanting softly. The roommate summons the nurse, complaining about the noise and the odor despite the fact the curtain is drawn between the beds. What is the most appropriate action by the nurse? 1. Tell the client's family the noise and odor bothers the roommate. 2. Move the elder to a private room so family can continue ceremony. 3. Offer to move the roommate to another room in a quieter area. 4. Explain the client is dying and the family will soon be leaving.

3. Correct: The most appropriate action in this situation is to move the roommate to a quieter location, allowing the family and dying client privacy while also fulfilling the roommate's request.

A frightened client comes to the nurses' station during the night and reports hearing the voice of the devil speaking to them. Which response by the nurse is priority? 1. "Could you have overheard the staff talking at the desk?" 2. "I will get you some medication for anxiety." 3. "What did the voice tell you? " 4. "You do not have to worry about this. You are safe."

3. Correct: The most important thing the nurse needs to find out is what the voice was telling the client. This is a safety issue. The nurse needs to know if the voice was telling the client to harm themselves or others.

A client admitted to the Coronary Care Unit (CCU) following a myocardial infarction (MI) expresses fear of the equipment and noise in the busy unit. What is the most therapeutic response by the nurse? 1. "Everyone gets scared here at first." 2. "Why are you afraid of equipment?" 3. "This all seems frightening to you." 4. "You won't have to be here very long."

3. Correct: The nurse is making a statement that reflects back the feeling of fear expressed by the client. This therapeutic communication tool acknowledges that the nurse has heard the client while providing an open-ended approach which will allow the client to continue to communicate emotions. Encouraging the client to continue to express feelings is important.

A woman who is 2 weeks postpartum calls the clinic stating "All I do is cry. I am so exhausted that I can't think clearly. I can't handle this anymore." What would be the most appropriate response by the nurse? 1. "You are being too hard on yourself. Being a mom is hard. Try to cheer up." 2. "It's normal to feel a little down after having a baby. Just give it some time." 3. "Have you had any thoughts of harming yourself or the baby?" 4. "When the baby starts sleeping better and you get some rest, your thinking will get better."

3. Correct: This mother seems to be experiencing more than the baby blues that many new mothers experience. There are clues in the stem of this question that you should recognize as warning signs of something more significant than the baby blues. The mother states that she no longer is thinking clearly and expresses that she can no longer cope with the existing situation. This mother seems to be experiencing postpartum depression that can include more severe symptoms such as suicidal thoughts of thoughts of causing harm to the baby. Therefore, it is crucial that the nurse ask a very straightforward, direct question to the mother to assess if the mother has any thoughts of harming herself or the infant. Failure to do so could put the mother and/or infant's life at risk for harm.

A client who is experiencing paranoia is very agitated with aggressive behavior and shouts at others when it is time for a group therapy session. Which action by the nurse is correct? 1. Ask the client to sit for a few minutes. 2. Explain that shouting is not allowed. 3. Redirect the client to another activity. 4. Inform the client that their actions are unacceptable.

3. Correct: Yes! Get them active. Redirect their activity. This is too much for them right now.

The nurse is caring for a client and the family at a time of impending death for the client. What comment by the nurse would best assist the family to cope with their grief during this time? 1. "Don't cry. Your family member would not want it this way." 2. "Things will be fine. You just need to give yourself some time." 3. "Try not to be upset in front of your family member." 4. "I'm so sorry. This must be very difficult for you."

4. Correct: Nurses can best facilitate the family's expressions of grief by supporting and encouraging them to express themselves. This is the best option that best demonstrates that expressions of grief are acceptable and expected. Here, you are empathizing to provide emotional support during their grief and providing an open ended statement that would promote expression of the family members' grief.

A military veteran with a history of post-traumatic stress disorder (PTSD) has arrived at the Crisis Center reporting an increase in nightmares, depression and anxiety. The nurse is aware the client would obtain the most immediate relief with what intervention? 1. Increase dose of antianxiety medications. 2. Greater family support interaction. 3. Referral to community support group. 4. Opportunity to verbalize memories.

4. Correct: PTSD is an emotional response to a traumatic event, usually beginning within several months of the event, although it can be delayed for years. When a client in severe distress arrives at the Crisis Center, the priority intervention must focus on relief of client's symptoms. The best non-invasive method to alleviate symptoms is encouraging the client to verbalize both memories and feelings. Though some individuals want to forget the incident, most clients experience a decrease in anxiety by discussing the event.

The nurse is bathing a confused client in the acute care unit. The nurse talks with the client and explains each procedure. During the bath, the client becomes very agitated. What should the nurse do? 1. Complete the bath as quickly as possible. 2. Reassure the client and request them to stop acting out. 3. Continue bathing with assistance from an unlicensed assistive personnel. 4. Stop the bath, dress and reassure the client.

4. Correct: The nurse should not continue bathing if the client is becoming so distressed. Perhaps the bath can be completed at a later time. Safety is the priority.

A client with a history of schizophrenia is currently being treated in a mental health facility. The client wants to vote in an upcoming election. The nurse understands what is true about the legality of this action? 1. Primary healthcare provider can decide if client may vote. 2. Psychiatric clients cannot vote if taking medication. 3. A lawyer must approve the finished ballot. 4. An absentee ballot from the polling place can be obtained.

4. Correct: There are very few reasons that a United States citizen would lose the right to vote in any election, and those few are mostly legal violations. A client who is hospitalized, whether in a medical or psychiatric facility, still retains the right to vote. The nurse, or facility designee, must advocate for this client by obtaining an absentee ballot, following the laws of that state, and is required to provide privacy for the client to complete that ballot.

What is the priority nursing intervention when caring for a client with an eating disorder? 1. Encourage the client to cook for others 2. Weigh the client daily and keep a journal 3. Restrict access to mirrors 4. Monitor food intake and behavior for one hour after meals

4. Correct: Yes, this is the primary problem and the most life-threatening. Provide a pleasant, calm atmosphere at mealtime and one hour after meals. Meal times become episodes of high anxiety and monitoring for one hour after prevents the client from vomiting up food.