NCLEX Psychiatric

The nurse is caring for a client who presents to the mental health unit following a violent altercation with the spouse. The client has numerous bruises on the face, chest, and back. There is one laceration where spouse "came at me" with a knife. At this time, what is most likely to be the mood of the perpetrator in this situation? 1. Extreme anger 2. Anxiety 3. Kindness 4. Irritability

3. Kindness (3. Correct: The perpetrator has completed the acute battering phase and has now likely entered the honeymoon phase with extreme kindness and acts of love. The attacker is now calm after the tension has been released. You may witness remorseful and apologetic behaviors like bringing gifts and promises of love. 1. Incorrect: The anger phase is likely over after the attacker has beaten the victim. This anger building stage is called tension building stage and is characterized by minor incidents like pushing, shoving and verbal abuse. During this time the abused spouse may accept the abuse for fear of it getting worse so the abuser rationalizes that the behavior is acceptable. The abuser may even turn to alcohol and drugs to curb the anger. The extreme anger exhibited during the acute battering stage. The abuser releases the built-up anger and tension by brutal and uncontrollable beatings. After the beating the client is calm and described as "in shock" or have have amnesia of the event. You also see extreme anger in the escalation/de-escalation stage. 2. Incorrect: The tension or anxiety would be felt during the tension-building phase. This anger building stage is called tension building stage and is characterized by minor incidents like pushing, shoving and verbal abuse. During this time the abused spouse may accept the abuse for fear of it getting worse so the abuser rationalizes that the behavior is acceptable. The abuser may even turn to alcohol and drugs to curb the anger. The extreme anger exhibited during the acute battering stage. The abuser releases the built-up anger and tension by brutal and uncontrollable beatings. After the beating the client is calm and described as "in shock" or have have amnesia of the event. You also see extreme anger in the escalation/de-escalation stage. 4. Incorrect: Irritability would be demonstrated during the tension-building phase.)

A schizophrenic client tells the nurse, "The president just told me to leave the hospital immediately because a spy is on the way to tap into the secret information in my brain." What is the nurse's best response? 1. The voice you heard is because of your illness and will go away in time. 2. I know you think the president is talking to you, but I do not see the president. We are the only ones here. 3. I find it hard to believe that you have talked to the president. This is not the White House! 4. I think the primary healthcare provider needs to increase your medication dose, since you are still hearing voices.

2. I know you think the president is talking to you, but I do not see the president. We are the only ones here. (2. Correct: The correct answer is to present reality. When a client has a misperception of the environment, the nurse defines reality or indicates his or her perception of the situation to the client. This delusion is called "thought withdrawal". It is the belief that thoughts have been removed from one's mind by an outside agency. 1. Incorrect: This response gives reassurance. In fact, it is false reassurance because the voices may not completely go away. Remember that the client believes what they think is real. You are not going to help them by blaming it on their illness. 3. Incorrect: This response is disagreeing. Never challenge the client or belittle the client with your response. 4. Incorrect: This response gives an opinion and does not bring reality into the conversation. You need to report the hearing of voices, to the primary healthcare provider, but this is not therapeutic for the client.)

The community health nurse is developing a presentation for adolescents on dealing with gun violence in school. What initial action should the nurse take? 1. Design a booklet for school districts on handling aggression. 2. Survey students to determine attitudes towards weapons. 3. Provide information on anger management to grade schools. 4. Investigate existing safety procedures in the schools.

2. Survey students to determine attitudes towards weapons. (2. Correct: Based on teaching/learning theory, the most important initial step is to determine if the client (in this case, a group of adolescents) is receptive to learning. Motivation is vital to successful learning. By first surveying student attitudes, the nurse gathers the data needed to prepare an age appropriate presentation that is more likely to be successful. 1. Incorrect: In this option, the nurse is implementing an action without collecting appropriate data. In addition, a booklet, while useful, is not what the nurse is to prepare. The correct issue is gun violence, not general aggression. 3. Incorrect: While it is true that anger management can influence violence, particularly at a young age, it is not the issue in this question. The idea of presenting information at the grade school level is logical but this nurse is to prepare an adolescent-based presentation. 4. Incorrect: This option does discuss collecting data; however, the information being collected does not address the topic in the question, which is gun violence. Safety procedures in schools could focus on many diverse concerns other than the issue of gun violence.)

A nurse is caring for a client injured in a motor vehicle accident while driving intoxicated. After hearing that someone was critically injured because of the accident, the client mumbles, "But I only had just a few drinks". What is the most therapeutic statement the nurse could make to the client? 1. "If you only had a few drinks, how did you wreck?" 2. "What do you mean by 'just a few drinks'?" 3. "Tell me what you remember about the accident." 4. "You were driving when the accident happened."

3. "Tell me what you remember about the accident." (3. Correct: While providing care to this client, it is important for the nurse to remain professional and non-judgmental. Because no life-threatening injuries are indicated, the most therapeutic approach would be to allow the client to verbalize feelings at this time. Additionally, having the client recall any specifics about the incident may provide the nurse with additional data for a neuro assessment. 1. Incorrect: Though it may be challenging to remain non-judgmental, this response demands an explanation from the client and can seem threatening. The client may have no memory of the accident; furthermore, although the client was intoxicated, there may be unknown circumstances that contributed to this accident. 2. Incorrect: This response might be helpful in situations where the nurse needs to determine the amount of alcohol a client ingests on a daily basis. However, in this circumstance, the amount of alcohol is not the issue for the nurse. The legal authorities may pursue this line of questioning. 4. Incorrect: This is a closed-ended statement that does not provide the client an opportunity to verbalize feelings. The nurse is making a statement that may, or may not, be factual. This would not be therapeutic to the client.)

The nurse is developing the plan of care for a newly admitted client diagnosed with schizophrenia. What goal would the nurse consider a priority for this client? 1. Schedule alone time for client to relax. 2. Frequently reorient the client to surroundings. 3. Encourage participation in all social activities. 4. Assign same staff to provide client care daily.

4. Assign same staff to provide client care daily. (4. Correct: Schizophrenia is a group of psychotic disorders characterized by thought disturbances, bizarre behaviors and social withdrawal. Because of the numerous emotional and psychologic dysfunctions, there are many possible goals. However, the priority objective is to help the client develop a trusting relationship in order to achieve other goals. Assigning the same staff to provide care daily is the first step toward that objective. 1. Incorrect: Clients with schizophrenia tend to self-isolate due to paranoid thoughts or hallucinations. Social withdrawal is a problem with these individuals and should not be encouraged by the nurse. Relaxation is not a priority goal for this client. 2. Incorrect: This client was just admitted with schizophrenia. Getting this disorder under control will take some time, requiring both medications and therapy. Reorienting the client to the surroundings frequently is important but not the priority at this time. 3. Incorrect: During the initial treatment period, the client may display hostility or angry, defensive behaviors which make group activities inappropriate. Eventually the client can be encouraged to participate in reality-based events but not in this early phase.)

A client who is scheduled for a total hip replacement surgery in the morning begins to verbalize anxiety related to the surgery. Arrange the client's comments in order as the client's anxiety advances beginning with mild to panic anxiety. "My Dad died on the operating table, and I keep thinking I will die too." "I know those hip exercises after the surgery are painful." "Can I wear my wedding ring during the surgery?" "Having trouble thinking about anything but the surgeon cutting on my hip."

"Can I wear my wedding ring during the surgery?" "I know those hip exercises after the surgery are painful." "Having trouble thinking about anything but the surgeon cutting on my hip." "My Dad died on the operating table, and I keep thinking I will die too." (The client is experiencing mild anxiety when asking a question about whether their wedding ring needs to be removed during surgery. The client is concerned about the ring, and is able to ask a direct specific question. Mild anxiety includes feelings of worrying and apprehension. Expressing a negative concern about their ability to complete the hip exercises after surgery is an example of moderate anxiety. The client is worrying about the hip exercises which is causing an increase in the anxiety level. The client is worried about the surgeon cutting on their hip. The physical action of cutting the hip is very troubling for the client. The client's continuous worrying is causing the client to have decreased ability to concentrate. This action indicates an increase in their anxiety level to severe. The client is expressing panic anxiety with the statement of feelings of impending doom. If the client's father had died on the "operating table", then there is a possibility that the client will also die during the surgery.)

The adult child of a client diagnosed with bipolar disorder asks the nurse if they will one day be diagnosed with the same disorder. What is the nurse's best response? 1. "There is a familial tendency for developing this disorder; however, it doesn't mean you will definitely develop this disorder." 2. "You should not worry about developing this disorder. You are young and healthy." 3. "If you were going to develop this disorder, you would have it by now." 4. "You have not been exposed to anything that would contribute to the development of this disorder, so you will not develop this disorder."

1. "There is a familial tendency for developing this disorder; however, it doesn't mean you will definitely develop this disorder." (1. Correct: Studies to determine if an illness is familial compare the percentages of family members with the illness to those in the general public or within a control group. Bipolar disorder is an example of a psychiatric illness with familial tendencies. Other psychiatric illnesses include schizophrenia, major depression, anorexia nervosa, panic disorder, somatization disorder, antisocial personality disorder, and alcoholism. 2. Incorrect: This adult child has a predisposing risk of developing this disorder. Do not give the adult child false assurance. Awareness of the family tendency will promote early detection and treatment. 3. Incorrect: There is no particular time frame for developing this disorder. You are brushing off the adult child here and not providing accurate information. 4. Incorrect: Exposure to outside elements is not indicative of development of this disorder. Do not dismiss the adult childs concern ever but surely not with inaccurate information.)

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. "This medication will help me control my behavior." 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. 2. Incorrect: Antipsychotic medications such as chlorpromazine cannot be stopped and restarted suddenly because of potential side effects. The medication must be taken consistently in order to control severe anxiety or agitated behaviors. 3. Incorrect: While some psychiatric medications may need to have blood levels monitored frequently, chlorpromazine is not one of those drugs. 4. Incorrect: There is no cure for schizophrenia. This disorder is because of alterations in normal brain chemistry, and although medications can alleviate or control the behaviors, the disorder can only be managed.)

An elderly male client's wife recently died unexpectedly. During the clinic visit, the client appears tearful, lacks eye contact, and the clothing appears disheveled. What would be a priority nursing assessment for the client? 1. Adaptive and coping skills for dealing with loss 2. Intellectual capacity to make personal decisions 3. Socioeconomic status for independent living 4. Spiritual awareness for emotional comfort.

1. Adaptive and coping skills for dealing with loss (1. Correct: The unexpected death of a spouse can elicit a wide variety of emotions due to the grief that is being experienced. Individuals who are grieving often find it difficult to seek help, even from close family members. Elderly clients tend to wish to retain their independence. They often do not want to be burdens to the family members, but may find themselves unable to cope effectively. In this case, the signs of ineffective coping is the lack of eye contact and the personal appearance of the client. The nurse should assess the client's ability to adapt and cope with the unexpected loss and work through the grief process. 2. Incorrect: Although intellectual capacity in this elderly client could impact decision making, the priority assessment at this time is the client's ability to adapt to this sudden loss and determine if the client has the needed coping skills to effectively work through the grief process. 3. Incorrect: With the loss of the spouse, there may be a decrease in income. This could create a financial strain on the elderly client. However, this is not the priority assessment at this time. The nurse should focus on the client's ability to work through the grief. 4. Incorrect: Spiritual awareness can be paramount in the life of an individual, and can certainly be important during times of loss. However, this client does not seem to be coping well with the loss of the spouse, so the priority at this time would be focused on assessing the skills that the client possesses to help adapt to the loss and have the ability to cope.)

A client who is Chinese comes to the clinic for a follow-up appointment following cardiac bypass surgery. The client's father accompanies the client into the examination room. What is the most appropriate action by the nurse? 1. Ask the client's father if he has any questions regarding his son's condition. 2. Ask the client's father to leave the examination room due to confidentiality. 3. Perform needed assessments and care without interacting with the father. 4. Inform the father of the assessment findings and plan of care.

1. Ask the client's father if he has any questions regarding his son's condition. (1. Correct: The nurse is responsible for providing culturally sensitive client care. In the Chinese culture, it is important to show respect to the elders of the family. This option respects the client's father by addressing him personally and providing a sense of involvement in the client's health. This option does not ignore the client's father nor does it violate the client's confidentiality. In addition, questions about certain conditions can be answered without direct reference to the client. 2. Incorrect: Asking the father to leave the exam room would be disrespecting not only the father, but also the client who allowed the father to be present. 3. Incorrect: By failing to acknowledge the presence of the father, this demonstrates a lack of respect for the elder of the family. The nurse should not ignore the presence of others in a client room. 4. Incorrect: By providing information of assessment findings and plan of care, this could violate the client's rights to confidentiality. The client would need to provide expressed permission for specific information to be shared in the presence of another individual.)

A client with a history of schizophrenia was admitted with abdominal pain and has been undergoing diagnostic tests. When the nurse enters the room, the client is alone and looking at the wall and states "Why should I hurt them?" What would be an appropriate intervention by the nurse? Select all that apply 1. Directly ask the client "Are you hearing voices?" 2. State "Tell the voice that you do not want to hurt anyone." 3. Focus on reality based topics of conversation. 4. Observe for signs of increasing anxiety in the client. 5. Tell the client "You know that you are not being told to hurt someone." 6. Inquire about what the client believes he or she is being told to do.

1. Directly ask the client "Are you hearing voices?" 3. Focus on reality based topics of conversation. 4. Observe for signs of increasing anxiety in the client. 6. Inquire about what the client believes he or she is being told to do. (1., 3., 4., & 6. Correct: Did you pick up on the cues that this client is experiencing auditory hallucinations? The most obvious cues that this client is hallucinating are the verbal response when there is no one present and the client is looking at the wall when responding. When you think a client is hallucinating, you should directly ask the client about the hallucination by asking such questions as: "Are you hearing voices?" In order to intervene with a client who is experiencing a hallucination, you should focus on reality-based diversions including reality-based topics of conversation. Also, hallucinations can be anxiety producing for clients, so you should observe for any signs of increasing anxiety, which can be a sign that the hallucinations are increasing. The nurse can explore the hallucination experience with this client by asking directly "What are the voices telling you to do?" Another way to specifically explore the hallucination with this client is to ask if they are being told to do something that would cause harm to someone. 2. Incorrect: You never want to react to the client's hallucinations as if they are real. In this case, you would not tell the client to talk back to the "voices" and argue with them or discuss things as if the voices are real. 5. Incorrect: You do not want to negate the client's hallucination experience, but you do offer your own perception that you do not hear the voices. Telling the client that they are not being told something would only escalate their anxiety and perhaps cause them to become irritable or upset. The voices are "real" to the client.)

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. During the end-of-shift report, assign specific staff to check on each client. (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. 2. Incorrect: This routine may or may not prevent an injury. The clients may learn the "routine" of the nurses and will perform the self-harming behaviors when the nurses are not likely to be making individualized checks on them. 3. Incorrect: Each client should be monitored daily at irregular intervals. Self-harming behaviors typically increase the risk of suicide in the client. The nurse should determine the level of imminent risk of suicide in the client. This should be routinely performed with client checks, not simply assessed on a daily basis. 4. Incorrect: It is not the clients' responsibility to check on each other. All clients have the right to a safe environment, and it is the responsibility of the nurses and healthcare team to provide this safety.)

A client is admitted with a diagnosis of disorganized schizophrenia. What characteristic should the nurse anticipate being manifested? Select all that apply 1. Evidence of loose associations 2. Use of neologisms and clang associations 3. Unpredictable or inappropriate emotional responses 4. Presence of stupor or presence of waxy flexibility 5. Suspiciousness and delusions of persecution 6. Flat or inappropriate affect

1. Evidence of loose associations 2. Use of neologisms and clang associations 3. Unpredictable or inappropriate emotional responses 6. Flat or inappropriate affect (1., 2., 3., & 6. Correct: Disorganized schizophrenia is characterized by social withdrawal and disorganization in speech, behavior, and emotional expression. One of the characteristics that you may see in a client with disorganized schizophrenia includes evidence of loose associations in which the client rapidly shifts topics when speaking without any logical connection between the thoughts. Clients with disorganized schizophrenia may also use neologisms which are made up words that only have meaning to them, or they may have clang associations where they use words that typically rhyme but have no connection in meaning. Unpredictable or inappropriate emotional responses are common in clients with disorganized schizophrenia. They have a lack of impulse control and exhibit behaviors that are bizarre or lack purpose. Even activities of daily living can be difficult or impossible for the client to complete. These clients often exhibit flat or inappropriate affect. Their facial expressions, voice tone, and mannerisms may show little or no emotion or have responses that are inappropriate to the situation. 4. Incorrect: Presence of stupor or presence of waxy flexibility are characteristics of catatonic schizophrenia. There can be a total lack of psychomotor activity or you may see the client assume a position that is maintained until moved by another person. Once moved, the client then maintains that set position. 5. Incorrect: Suspiciousness and delusions of persecution are classic signs of paranoid schizophrenia.)

A client is admitted to the hospital due to alcohol toxicity. Which interventions should the nurse initiate? Select all that apply 1. Pad side rails 2. Attach client to pulse oximeter 3. Monitor closely for hyperthermia 4. Place in recovery position 5. Monitor fluids and electrolytes

1. Pad side rails 2. Attach client to pulse oximeter 4. Place in recovery position 5. Monitor fluids and electrolytes (1., 2., 4. & 5. Correct: Alcohol toxicity can lead to behavior changes and alcohol-induced central nervous system depression which can lead to respiratory and circulatory failure. The client can also experience unconsciousness, or coma leading to possible death. The client can also experience hypokalemia, hypomagnesemia and hypoglycemia. Client is at risk for seizures so pad the side rails. Client is at risk for hypoventilation and may stop breathing. Pulse oximeter will measure oxygen levels. The recovery position decreases the risk for aspiration. Alcohol has a diuretic effect, so I&O should be monitored. 3. Incorrect: Due to the fluid shift, this client is at a higher risk for hypothermia. The client with alcohol toxicity is not at risk for hyperthermia.)

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. Victims of abuse are likely to report injuries and causes that do not fit the normal profile. (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. 2. Incorrect: Though many IPVs are from low income families IPV occurs across all socioeconomic levels and cultures. All suspected IPV cases should be assessed and reported regardless of their socioeconomic levels and cultures. 3. Incorrect: Men are also victims of IPV, though not as frequently as women. All potential victims should be assessed and reported if needed. 4. Incorrect: Many times the perpetrator will come to the emergency department (ED) with the victim. The victim may be afraid to give an accurate report of the accident with the perpetrator in the ED exam room. If so, more discreet screening is necessary.)

The nurse overhears this client responding on the phone when their boss asks them to work an extra night shift. Which statement by the client demonstrates assertive communication? 1. "I know you are joking! I have already worked an extra night shift." 2. "I do not want to work an extra night shift. I have already worked an extra shift this week." 3. "Umm, well, okay. I guess I will work an extra night shift." 4. "Okay, I'll work an extra night shift." Then they say to another client. "The nerve of my boss to ask me to work another extra shift."

2. "I do not want to work an extra night shift. I have already worked an extra shift this week." (2. Correct: This is an example of assertive communication, the best response. Assertiveness is asking for what one wants or acting to get what one wants in a way that respects the rights and feelings of other people. 1. Incorrect: This response is aggressive behavior. This response is delivered in a forceful manner. 3. Incorrect: This response is nonassertive. This statement is giving into the boss, even though the client really doesn't want to work. Keywords are "umm, well and okay" 4. Incorrect: This response is Passive-Aggressive. It is the indirect expression of anger.)

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. "The therapy must be difficult for you at times. How do you feel about your progress at this point?" (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. 1. Incorrect: This response gives false reassurance which is inappropriate and negates the therapeutic trusting relationship between the nurse and the client. 3. Incorrect: This response is a trite expression or cliché which minimizes the importance of the client's feelings. This is also a close-ended statement that does not allow for any further expression of feelings by the client. 4. Incorrect: This response is demanding an explanation for the client's thoughts, feelings, or events. It makes the client have to be defensive.)

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.

2. Assess client for any suicidal behaviors. (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. 1. Incorrect: While it is true that encouraging the client to verbalize feelings is therapeutic in a crisis, that is not the most important initial action by the nurse at this time. Recall the nursing process when considering an irrational action. 3. Incorrect: Arriving at a mental health crisis center does not automatically require admission to the hospital. This client is overwhelmed by circumstances which include the death of a family member; however, ideally the client may respond to counselling or medications without the need for inpatient care. 4. Incorrect: Following evaluation by a primary healthcare provider, this client will definitely receive counseling, perhaps both individualized and in a support group for those under extreme duress. However, this is not the initial concern for the nurse.)

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. I will notify the primary healthcare provider about your headaches, after the group session. (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. 1. Incorrect: This is a nontherapeutic response. The client's feelings and concerns should not be denied. This will increase the anxiety level of the client. Do not totally ignore the client's complaint. 3. Incorrect: By postponing the group session the nurse is reinforcing the clients somatization disorder. The group session should start on time. 4. Incorrect: The pain is real to the client. This response is not therapeutic communication. The direct ignoring of the client's complaint will increase their anxiety level.)

How would a tendency toward stereotyping and countertransference affect the nurse's ability to complete a client's cultural assessment? 1. Facilitate the care planning process. 2. Promote decisions based on the nurses value system. 3. Utilize an open honest approach while responding to the client's concerns. 4. Develop an unbiased approach to care.

2. Promote decisions based on the nurses value system (2. Correct: Both stereotyping and countertransference will decrease the nurse's sensitivity to the client's needs and the culture they represent. Nurses who impose these values upon clients will make decisions based on their attitudes, values and beliefs and not those of the culturally different client. 1. Incorrect: Both stereotyping and countertransference also interfere with the treatment process you can't base your care plan on your general views toward a client's culture. Care plans, must be individualized and not based on stereotypes. 3. Incorrect: The nurse will make automatic responses based on preconceived ideas and expectations. The nurse is unable to be open and honest about client concerns. Remember, stereotyped behavior is based on the assumption that all people in a similar cultural, racial or ethical group think and act alike. 4. Incorrect: The nurse's need to maintain an unbiased care is important because the client's needs remain unmet. Value clarification by the nurse will assist in preventing stereotyping and countertransference to other clients. The nurse will never have an unbiased approach to care for clients unless the nurse understands and removes unhealthy values affecting the assessment process.)

An elderly client with dementia is being admitted to a long-term care facility. When orienting the client to the environment, what is the most important action for the nurse to take? 1. Provide nurse's name upon entering client's room. 2. Show client how to use the call bell in the room. 3. Provide a tour of the facility and grounds. 4. Instruct client on the location of emergency exits.

2. Show client how to use the call bell in the room. (2. Correct: Changes can be very overwhelming for an elderly client, particularly in the presence of dementia. The most important issue is to be sure the client understands how to summon staff at any point. Demonstrating the use of the call bell and allowing the client to provide a return demonstration is the most important action. 1. Incorrect: This client has dementia and therefore may not be able to process or remember names. This is an appropriate action, but remember safety first. 3. Incorrect: Though orientation to a new environment would be important, this client's mental status can be easily overwhelmed with too much information. The focus should be restricted to the most basic safety information that the client needs to know. 4. Incorrect: While emergency exits are critical information, a client with dementia has a limited ability to comprehend a large volume of new information all at once. Multiple exits, depending on the client's location in the facility, is too much complex information initially.)

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. "Have you had any thoughts of harming yourself or the baby?" 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. 1. Incorrect: This belittles the client's feelings of hopelessness and gives inappropriate advice to correct the problem on her own. The client might not share any further with the nurse and the situation could become much worse, including harm to her or the infant. 2. Incorrect: Although many mothers do experience baby blues in the postpartum period, you would be missing critical signs that this situation is more than the baby blues if you make the statement that many mothers feel a little down and to just give it some time. During that time, this postpartum depression that was not identified could continue to worsen to the point of more severe symptoms and possible harm to herself or the infant. 4. Incorrect: Although a lack of sleep may be a factor, telling the mother that it will get better later will not give this mother the help that she needs now. Never delay care when the health and well-being of the mother and infant could be at risk.)

The nurse is assessing an adolescent newly diagnosed with obsessive compulsive disorder (OCD). The client is nervously rearranging papers on the desk and stating "why can't I stop this?" What would be the most therapeutic response(s) by the nurse at this time? Select all that apply 1. "We can help you control impulses, but you will never be cured." 2. "You will feel much better after beginning your family therapy." 3. "Tell me what part of your disorder you find the most difficult." 4. "You seem nervous and upset about rearranging those papers." 5. "The goal of behavior control can be accomplished with help."

3. "Tell me what part of your disorder you find the most difficult." 4. "You seem nervous and upset about rearranging those papers." 5. "The goal of behavior control can be accomplished with help." (3., 4., & 5. Correct: The key in the nurse/client relationship is that interaction must be therapeutic and open-ended to encourage the client to share feelings in a nonthreatening environment. The nurse is asking the client to provide some details about living with the disorder by using a broad opening statement about the challenges of the disorder. Then the nurse is reflecting the client's behavior, indicating a perceived sense of anxiety or being upset. Finally, the nurse is addressing the client's verbalized concerns by stating the probable success of the main treatment goal, thus encouraging the client. 1. Incorrect: Though there is truth behind this statement, such a negative comment does not provide any hope or comfort to the client. The information is presented in a non-therapeutic manner. 2. Incorrect: There is often a component of psychotherapy, or "talk therapy" involved in the treatment of OCD. However, this disorder does not require family therapy, but rather individual analysis to help the client understand or control anxiety.)

An elderly client is to be ambulated for the first time following a hip replacement. The client refuses to get out of bed, indicating an extreme fear of falling. What statement by the nurse is most therapeutic? 1. "Don't be afraid because I will not let you fall." 2. "Your doctor says you must walk twice today." 3. "I'll get another nurse to help so you won't fall." 4. "What worries you most about getting out of bed?"

4. "What worries you most about getting out of bed?" (4. Correct: The nurse needs to focus on the client's psychological as well as physical needs. An open-ended question or statement encourages the client to elaborate and share concerns that the nurse needs to address. It would be inappropriate to force the client to participate in an activity that causes extreme fear and distress. 1. Incorrect: The nurse is dismissing the client's right to experience a specific emotion, rather than actively seeking the reason behind those feelings. The nurse is not utilizing appropriate communication techniques. 2. Incorrect: This tactless response focuses on the orders provided by the primary healthcare provider, rather than the client's expressed concerns. Such a comment by the nurse is non-therapeutic because it ignores the client's psychological needs. 3. Incorrect: Although the nurse offers a solution to the client, there is no chance for the client to verbalize feelings and concerns. It is more important to present the client with the therapeutic opportunity to discuss fears.)

The nurse is talking with several high school students after a classmate from their school died in a motor vehicular accident. Which statement by the nurse is therapeutic? 1. "Sometimes bad things happen to people we care about." 2. "I was so upset that the student who died had been drinking." 3. "Why are you angry? Tell me how you feel about losing your friend." 4. "What would you like to talk about concerning the loss of your classmate?"

4. "What would you like to talk about concerning the loss of your classmate?" (4. Correct: The therapeutic communication technique of giving broad openings will allow the students to move the topic of the death of their classmate in the direction of their choice. The students will feel more freedom to communicate with the nurse and the other students. 1. Incorrect: The high school students are experiencing the grief process due the death of one of their classmates. The nurse is showing a lack of understanding about the feelings of the students. The students will not experience any relief from their grief by stating that others have lost persons they cared about. This statement is an example of the nontherapeutic technique of belittling feelings expressed. 2. Incorrect: The nurse is utilizing the nontherapeutic communication technique of expressing disapproval. The students may respond by being unsettled or resentful at the nurse. This will block the communication pathway, and the students will not be receptive to what the nurse as the group leader is communicating. 3. Incorrect: The nurse is stating that the students are angry without the students sharing their feelings. Beginning the statement with the word why implies that the nurse already has identified what emotion the students have. This presumption of anger may not be correct, and students may not express their feelings freely. This is the nontherapeutic communication of requesting explanation.)

A homecare client with terminal cancer is taking morphine sulfate and reports the current dose is no longer relieving the pain. What would the nurse tell the client about the increased discomfort? 1. The pain medication will need to be taken consistently around the clock. 2. A different pain medication will need to be prescribed since addiction has occurred. 3. As the cancer spreads, the pain medication will no longer help. 4. A tolerance to the current dose has occurred, so the dose will need to be increased.

4. A tolerance to the current dose has occurred, so the dose will need to be increased. (4. Correct: Tolerance occurs when a client no longer experiences the same effect from a specific dose of medication and requires a larger dose to achieve the desired effect. The client has been using morphine for pain control and is no longer experiencing the same level of relief. This is an expected result of long term use with certain medications. 1. Incorrect: While inconsistent scheduling of medication doses can cause blood levels of the morphine to fluctuate, it is unlikely this client would skip or miss a dose to treat on-going cancer pain. 2. Incorrect: Addiction is a behavioral/physical compulsion to utilize a particular drug regardless of its negative consequences, side effects, cost, loss of family, friends and employment. An addicted individual craves the drug both psychologically and physically, and does not use the medication for its intended purpose. 3. Incorrect: As pain worsens and the intolerance to the morphine increases, the dosage can also be increased so that the client does not suffer in pain.)

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. 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. 1. Incorrect: The primary healthcare provider has no authority over the client's ability to cast a vote. Regardless of any mental health diagnosis, this client still retains the legal right to vote in any election. In fact, notifying the primary healthcare provider of the client's intent to vote violates the client's privacy. 2. Incorrect: Whether a client takes medication does not affect the client's right to cast a ballot in any election. Refusing this client, the right to vote based on medication use would be considered discriminatory. 3. Incorrect: A lawyer is not required to approve either the client's voting rights, or the completed ballot. In fact, having anyone else look at the client's ballot would be a violation and is definitely illegal. A client's ballot is private and protected by both state and federal law.)

A client has been admitted for evaluation of severe anxiety and new onset panic attacks following the loss of a spouse. Which client factor would the nurse consider most important in developing a plan of care? 1. Available support system 2. Perception of the situation 3. Desire to return to work 4. Coping mechanisms

4. Coping mechanisms (4. Correct. The plan of care for a client in crisis involves a complex combination of factors to achieve a positive outcome. However, the most important consideration is the client's own coping skills. Treatment and subsequent recovery is more successful when the client has the coping skills and is able to participate in the recovery process. 1. Incorrect. Although a good support system is crucial during any psychiatric or emotional crisis, this is not the most important aspect of a client's plan of care. The priority is the client. Available support systems is not the priority when developing a plan of care. 2. Incorrect. The client's own perception of the problem can enhance or detract from a successful outcome; however, there is another facet that is more critical to a client's positive outcome. The client's coping mechanisms can affect their perception of the situation. 3. Incorrect. Having a goal, such as returning to employment, is important to the client's recovery, but by itself is not enough to ensure a positive outcome for a client. Returning to work is not the priority with new onset panic attacks.)

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. 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. 1. Incorrect: The client should be identified by 2 identifiers such as the name and birthday, name and medical record number. 2. Incorrect: The tubes and indwelling lines should be removed prior to cleansing the body. Safety standard precautions should be initiated during the removal procedure. 3. Incorrect: After cleansing the body the dentures should be inserted to maintain facial shape. The family can view the body after the dentures are inserted.)

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. 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. 1. Incorrect: The client is obviously distressed. Continuing the bath could jeopardize the safety of the nurse and client. 2. Incorrect: Reassurance may not work with the confused client. It is difficult to know exactly why the client is becoming so distressed. The safety of the client is important. 3. Incorrect: Adding a second person will increase the feelings of powerlessness in the client. This could and will add to the client's distress. Stopping the procedure is the safest answer.)

A client in a psychiatric unit tells the nurse, "I wanted to take the car to work, but the train station took all the tracks. Driving is the ticket when you want to go to the movies. No one needs money in heaven. We have money in our foods." How should the nurse document this conversation? 1. Associative looseness 2. Circumstantiality 3. Echopraxia 4. Anhedonia

1. Associative looseness (1. Correct: Thinking is characterized by speech in which ideas shift from one unrelated subject to another in an unrelated manner. The person is not aware that the topics are unconnected. Speech may be incoherent at times. 2. Incorrect: With circumstantiality, the person is delayed in reaching the point of a communication because of unnecessary and tedious details. The point or goal is usually met, but only with numerous interruptions by the interviewer to keep the person on track. The person gets caught up in countless details and explanations. 3. Incorrect: The client who exhibits echopraxia may imitate or mimic the movements made by others. 4. Incorrect: Anhedonia is the inability to experience pleasure in acts that are normally pleasurable.)

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. Encourage the client to focus on reality-based issues. (1. Correct: Get them out of the fantasy and into the real world. 2. Incorrect: Do not allow client to continue in a fantasy, this is reinforcing it. 3. Incorrect: This is not appropriate as the client is talking about a delusion. 4. Incorrect: This is not the appropriate time for stress reduction techniques. Yes, the client should use stress reduction techniques but not during the auditory delusion.)

An emergency room nurse is assessing a child with a suspicious spiral fracture to the right arm. The nurse is aware the best evidence to support possible child abuse is what? 1. Inconsistency between injury and explanation of the cause. 2. Child withdraws when the parent tries to hug or comfort. 3. Parents leave the room when questioned about the injury. 4. Lack of parental concern with injury or pending treatment.

1. Inconsistency between injury and explanation of the cause. (1. Correct: The best evidence to support suspicion of child abuse is an inconsistent story between how the injury occurred and the injuries noted in the child. There may be additional signs noted by the nurse, but specific details about what led to the injury, compared to the physical assessment, provides clear evidence for possible abuse. 2. Incorrect: While most children become clingy when an illness or injury occurs, withdrawing from a parent is not clear evidence of abuse. It could be an indication of dysfunctional parenting or incomplete bonding, but not necessarily child abuse. 3. Incorrect: Though most parents seem very concerned and are overly attentive, others may be overcome with grief that the incident happened. When questioned about the cause of the injury, a parent may exit the room, overcome by a sense of guilt and responsibility for the occurrence. This action is not true evidence of child abuse. 4. Incorrect: Parental response to an injured child widely varies and can be inconsistent based on multiple factors, such as sex and age of child, personal perceptions, cultural practices and even the circumstances of the event. Parents can become so overwhelmed by the incident that even non-abusive parents may seem indifferent while trying to remain strong.)

The nurse, caring for a client diagnosed with Alzheimer's Disease (AD), notices the client becoming agitated. What nursing strategies would be appropriate for the nurse to initiate? Select all that apply 1. Provide a snack for the client. 2. Tell the client to stop the unwanted behavior. 3. Take client for a walk. 4. Ask the client to sweep the floor. 5. Inform the client that restraints will be used if behavior continues. 6. Turn on the client's favorite music.

1. Provide a snack for the client. 3. Take client for a walk. 4. Ask the client to sweep the floor. 6. Turn on the client's favorite music. (1., 3., 4., & 6. Correct: Nursing strategies that address difficult behavior include redirection, distraction, and reassurance as provided by these correct interventions. 2. Incorrect: These behaviors are often unpredictable and not intentional. Do not challenge the client, use redirection, distraction, and reassurance. 5. Incorrect: When dealing with a difficult client, do not threaten to restrain the client or call the primary healthcare provider. A calming family member can be asked to stay with the client until the client becomes calmer.)

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. "You are repressing this event because it was frightening and painful for you." (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. 1. Incorrect: The nurse is being aggressive and judgmental which is inappropriate and not therapeutic for the client. 3. Incorrect: Undoing is canceling out a behavior or trying to make amends. This is not a correct assessment of what the client has reported to the nurse. 4. Incorrect: Splitting occurs when a person cannot stand the thought that someone might have both good and bad aspects, so they polarize their view of that person as someone who is "all good" or "all bad.")

The nurse is caring for a client in the emergency department following an argument with the spouse. The client describes a verbal argument that began to get physical with shoving of the client. There is a history of domestic violence. Which phase of the cycle of violence is the client describing? 1. Honeymoon phase 2. Tension-building phase 3. Acute battering phase 4. Remorse phase

2. Tension-building phase (2. Correct: In the tension-building phase, minor physical or emotional abuse may occur as well as verbal arguments. The victim feels growing tension and tries to control the situation. 1. Incorrect: The honeymoon phase is characterized by remorse with promises never to hurt the victim again. The abuser is sorry and apologetic. 3. Incorrect: The acute battering phase includes the release of tension through extreme physical violence. This is also called the explosion phase. 4. Incorrect: There is no remorse phase, but remorse is expressed during the honeymoon phase. There are 3 phases: tension building, acute battering (explosion) and honeymoon phase.)

A client has been admitted to the psychiatric unit with a diagnosis of schizophrenia. Which client behaviors does the nurse anticipate? Select all that apply 1. Abstract reasoning 2. Waxy flexibility 3. Grandiose delusions 4. Anxiety 5. Agitated behavior

2. Waxy flexibility 3. Grandiose delusions 4. Anxiety 5. Agitated behavior (2., 3., 4. & 5. Correct: Waxy flexibility describes a condition in which the client allows body parts to be placed in bizarre or uncomfortable positions for long periods of time. Delusions of grandiosity like believing they are a famous person or religious figure is a false fixed belief experienced by the client. If the client is in the acute phase of schizophrenia, the person may be overwhelmed by anxiety and is not able to distinguish thoughts from reality. It is thought that delusions may develop to cope with the anxiety. Agitated behavior like running about and going from one location to another can lead to exhaustion in this client. 1. Incorrect: This client has concrete thinking which implies over emphasis on specific details and an impairment in the ability to use abstract concepts. For example, during the nursing history you may ask the client what brought them to the hospital and the answer will be "a cab.")

Which statement by the spouse of a client diagnosed with Alzheimer's indicates to the nurse that the spouse is dealing appropriately with stressors? 1. "I am in charge of every aspect of the care provided." 2. "I do not expect our children who live out of town to help." 3. "I keep a list of small tasks ready for people who ask me if they can help." 4. "I only go to my primary healthcare provider when I am sick."

3. "I keep a list of small tasks ready for people who ask me if they can help." (3. Correct: Encourage caregivers to say "yes" when someone offers assistance. It's smart to have a list ready of small tasks that others could easily take care of, such as picking up groceries or driving the person to an appointment. 1. Incorrect: The caregiver should be willing to surrender some control. Delegating is one thing. Trying to control every aspect of care is another. People will be less likely to help if the caregiver micromanages, or insists on doing things their way. 2. Incorrect: The caregiver should spread the responsibility. Get family members involved as much as possible. Even someone who lives far away can help. Encourage the caregiver to divide up caregiving tasks. One person can take care of medical responsibilities, another with finances and bills, and another with groceries and errands. 4. Incorrect: Encourage the caregiver to stay healthy by keeping on top of primary healthcare provider visits. They should not skip annual routine, checkups, or medical appointments.)

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. Neologism (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. 1. Incorrect: With magical thinking, the person believes that their thoughts or behaviors have control over specific situations or people. The client believes that thinking something can make it happen. 2. Incorrect: With tangentiality, the person never really gets to the point of the communication. Unrelated topics are introduced, and the original discussion is lost. The client goes off the topic which can destroy interpersonal communications. 4. Incorrect: The person who exhibits perseveration persistently repeats the same thought, phrase or motor response to different questions. This is associated with brain damage.)

A client diagnosed with Alzheimer's disease tells the nurse, "I haven't eaten all day. When am I going to eat?" The nurse noted that the client ate 100% of the provided lunch 45 minutes ago. What would be the best way for the nurse to respond? 1. "I'll ask the kitchen if they can send you up another lunch." 2. "What makes you think you didn't eat lunch?" 3. "You ate lunch less than 1 hour ago." 4. "Would you like me to get you some crackers and milk?"

4. "Would you like me to get you some crackers and milk?" (4. Correct: The client believes that he/she has not eaten. Do not argue with the client. Offer the client something to eat. Fix the problem that the client believes he/she has. 1. Incorrect: The client wants to eat but another lunch is not needed since the client ate 100% of the provided lunch, just 45 minutes ago. A snack can be given. 2. Incorrect: Do not argue with the client. This will cause agitation and possible aggression. 3. Incorrect: Again do not argue with the client. The client does not believe he/she has eaten.)

A client being treated for major depressive disorder arrives at group therapy for the first time in a week wearing clean clothes after showering. What response by the nurse would be therapeutic? 1. "Why are you all dressed up for group?" 2. "Maybe you could add makeup tomorrow." 3. "You must feel better after finally showering." 4. "You look really nice in that flowered jacket."

4. "You look really nice in that flowered jacket." (4. Correct: When a depressed client has a sudden change in behavior or attitude, the nurse must cautiously evaluate any meaning behind such abrupt behavior. The best way to proceed is to engage the client in an interactive conversation by utilizing therapeutic techniques. This nursing comment provides positive affirmation of the client's actions by drawing attention to the choice of clothing. Open-ended statements provide a safe environment for building rapport and client interaction. 1. Incorrect: Demanding an explanation for behavior is always non-therapeutic. Most often, the client will have no response or even understanding of the behaviors and can become frustrated trying to respond. Additionally, this question could be interpreted as disapproving of the clothing, causing the client to return to previous behaviors. 2. Incorrect: The nurse is suggesting the client's attempts to improve self are less successful by inferring that makeup should be applied. This comment is not therapeutic, nor does it acknowledge the positive initial actions taken by the client. Rather than encouraging, such a response by the nurse is negative and not constructive. 3. Incorrect: While this statement does acknowledge the client has showered, the word "finally" has a negative connotation, suggesting the client has neglected personal care for an unacceptable amount of time. Such a comment by the nurse is non-therapeutic and discourages communication.)

The family of an elderly client are concerned about emotional well-being since the loss of the spouse two years ago. What alternative therapy could the nurse recommend for this client? 1. Massage 2. Bioelectromagnetics 3. Accupressure 4. Animal-assisted therapy

4. Animal-assisted therapy (4. Correct: Animal-assisted therapy is the use of specifically selected animals as a treatment modality in health and human service settings. It has been shown to be a successful intervention for people with a variety of physical or psychological conditions. The contributions companion animals make to the emotional well-being of people include providing unconditional love and opportunities for affection; achievement of trust, responsibility, and empathy toward others; a reason to get up in the morning, and a source of reassurance. 1. Incorrect: Massage therapy is the scientific manipulation of the soft tissues of the body. It is believed to aid the body to heal itself. 2. Incorrect: This uses electromagnetic fields to affect the functioning of cells, tissues, organs and systems. 3. Incorrect: Acupressure is a treatment rooted in the traditional Eastern philosophy of life energy, that flows through the body along pathways. It opens up blocked pathways to relieve pain.)

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. Agitation 2. Insomnia 3. Course tremors 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. 4. Incorrect: The onset of hallucinations indicates alcohol withdrawal delirium, a potentially fatal complication of alcohol withdrawal that occurs when the withdrawal process has not been medically managed. It begins the 2nd or third day after the client's last drink and lasts 48-72 hours. 5. Incorrect: Confabulation is a symptom of alcohol amnestic disorder or Korsakoff syndrome. Thiamine deficiency is thought to cause this syndrome.)

Which statement made by the nurse is therapeutic when the client, who has experienced deficits from a recent cerebral vascular accident, tearfully states, "I can no longer care for myself."? 1. "Right now, I am going to help you get dressed and eat breakfast." 2. "You have to focus on the positive things in your life." 3. "It is hard not to be able to care for yourself." 4. "All you need is some physical therapy and you will be back to normal soon."

3. "It is hard not to be able to care for yourself." (3. Correct: This statement shows a recognition of the client's feelings. 1. Incorrect: Changing the topic is a nontherapeutic response. 2. Incorrect: This statement deflects the client's feelings. 4. Incorrect: This statement is condescending and may not be true for this client.)

An elderly widower has been admitted to a psychiatric crisis unit with a diagnosis of major depression with agitation. What behaviors would the nurse expect to observe during an initial assessment? Select all that apply 1. Memory loss 2. Difficulty focusing 3. Excessive sleepiness 4. Short-tempered 5. Hand-wringing

2. Difficulty focusing 4. Short-tempered 5. Hand-wringing (2., 4., & 5. Correct: This type of depression is characterized by the added component of agitation. The client experiences difficulty focusing because of racing thoughts and restlessness. Other symptoms include incessant talking along with short-tempered outbursts of anger towards everyone. The inability to sit still is commonly accompanied by fidgeting or hand-wringing, which would be apparent to the nurse during an initial assessment. 1. Incorrect: Despite the client's agitation, racing thoughts and difficulty focusing, there is no actual memory loss at any point during this activity. 3. Incorrect: While excessive sleepiness may be typical of depression, the agitation which accompanies this disorder makes it very difficult to relax or sleep at all.)

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. Talk quietly to the client. (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. 1. Incorrect: Restraints are a last resort and can make the client more agitated. 3. Incorrect: The use of positive nursing actions can reduce the use of chemical (drug therapy) restraints. 4. Incorrect: Do not pick an answer that transfers the client away from the nurse's care.)

A nurse is caring for a client admitted with a diagnosis of depression and suicidal thoughts. The client states, "My husband doesn't love me anymore, and so life is just not the same." What would be the most appropriate response by the nurse? 1. "Even though your husband does not love you, life can still be very meaningful." 2. "Many couples go through difficult times in their marriage, but you should not assume that he does not love you anymore." 3. "Tell me what has led you to believe that your husband doesn't love you anymore." 4. "You really need to try not to let your husband make you depressed and feel that life is not worth living."

3. "Tell me what has led you to believe that your husband doesn't love you anymore." (3. Correct: During this initial assessment, the nurse should use therapeutic communication to try to explore the client's feelings and perceptions and demonstrate acceptance of the client. This can best be accomplished by allowing the client to discuss the events that played a role in the development of beliefs that her husband no longer loves her. 1. Incorrect: This dismisses the client's feeling that the worth of life is closely related to the relationship with her husband. The nurse should not make comments that negate the client's feelings. 2. Incorrect: Telling the client that couples go through difficult times and for her not to assume that the husband does not love her is communicating that her feelings are not valid. In addition, the nurse is using a cliché that all couples have problems which further invalidates her feelings in the situation she is experiencing. 4. Incorrect: Telling the client to try not to let the husband make her feel depressed is giving advice. This does not allow the client to verbalize or explore her feelings and does not provide the client with a sense of support from the nurse.)

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. Circulatory (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. 1. Incorrect: Blood glucose levels may become elevated while using this category of antidepressants, but hyperglycemia can be treated and controlled if the client responds well to the medication. This is not of greatest concern to the nurse. 2. Incorrect: Tricyclics increase body levels of norepinephrine and serotonin, and the client may experience drowsiness or e en blurred vision. The nurse will teach the client about safety precautions prior to discharge, but this is not the chief concern. 4. Incorrect: Although tricyclic antidepressant medication may increase appetite, cause constipation and weight gain, these are expected side effects and not of major concern.)

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. Client reports a fear of gaining weight. (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. 1. Incorrect: A decrease in clothing size does not indicate a problem. It may be an indicator of an eating disorder but in itself does not mean there is an eating disorder. 2. Incorrect: A client with an eating disorder may eat alone, or not at all. Eating with peers shows the feeling of acceptance which is not usually present with an eating disorder. 4. Incorrect: Eating snacks of fruit and vegetables is a healthy behavior. This alone does not contribute to an eating disorder. Also, it says the diet is "mostly" fruit and vegetables.)

A female client who identifies herself as a Muslim arrives at the outpatient clinic with abdominal pain. Which initial question should the nurse ask to obtain cultural information? 1. "Do you need a family member in the room with you?" 2. "What can you tell me about your culture?" 3. "Have I positioned you so that you are facing toward Mecca?" 4. "Are you comfortable being cared for by a male primary healthcare provider?"

4. "Are you comfortable being cared for by a male primary healthcare provider?" (4. Correct: Some Muslims will not feel comfortable with an RN or MD of the opposite gender. The nurse needs to find out prior to treatment. 1. Incorrect: Family is often important in this culture and the client may want a family member present. But initially, the nurse needs to find out who will need to care for the client. Is a male care giver acceptable? 2. Incorrect: The nurse needs to know about this culture, but most importantly, the nurse needs to know what, if any of their culture, is followed by the client. 3. Incorrect: A devout Muslim will prayer 5X a day. Bed-bound clients need to be positioned towards Mecca. It is not necessary for the client to continually face Mecca.)

An alcoholic client was admitted to the medical unit with substance-withdrawal delirium. Two days later, the client decides to leave the hospital against medical advice. What is the priority nursing intervention at this time? 1. Hide the client's clothes so that he cannot leave. 2. Administer the ordered sedative. 3. Place restraints on the client. 4. Determine why the client wants to leave.

4. Determine why the client wants to leave. (4. Correct: Always assess why the client wishes to leave first. This will provide an opportunity to attempt to fix the problem and possibly revise the client's decision. 1., 2. & 3. Incorrect: Confining a client against his or her wishes, except in an emergency situation, may be considered false imprisonment. Actions that may invoke these charges include: locking an individual in a room, taking a person's clothes for the purposes of detainment against his or her will, and retaining in mechanical restraints a competent voluntary client who demands to be released.)

What statement by the nurse would be most appropriate for a client who is exhibiting signs of escalating anger? 1. "You seem angry, but I can't understand why you would be upset." 2. "I notice that you are angry. Please share what you are thinking." 3. "You need to calm down. You will make the other clients upset." 4. "I am not going to be able to talk to you if you keep getting angry like this."

2. "I notice that you are angry. Please share what you are thinking." (2. Correct: When a client appears to be angry or is demonstrating signs of escalating anger, the nurse should recognize this and verbalize to the client what is seen or heard so that the client realizes that their feelings are being considered. This statement first shows reflection of the situation and recognizes that the client is angry. By doing this, it also allows the client to feel understood. The second part of the nurse's response expresses a desire to better understand the client and express empathy. This should be kept brief by simply asking the client to share the thoughts and feelings that are being experienced during this period of anger escalation. By gaining an understanding of the client's thoughts and feelings, you will be better equipped to intervene appropriately. 1. Incorrect: You have a client whose anger is escalating. Do you want to further agitate them by devaluing them and stating that you can't understand why they would be angry? Of course not! Commenting that the client seems angry would be acceptable, but belittling their emotional response would not be therapeutic. 3. Incorrect: Although the client's anger could make other clients upset, demanding that the client calms down would not be a good approach to take with this client. The client could possibly become more upset and belligerent, which would only complicate the situation more. The nurse should first try to understand what is going on with the client. Deescalating techniques would then be used to help calm the client. 4. Incorrect: Threatening comments, such as this one, by the nurse would probably inflame the situation. The nurse should attempt to understand the client's feelings and demonstrate empathy.)

An adolescent client, diagnosed with anorexia nervosa, discloses an incestuous relationship to a nurse. What is the most therapeutic response by the nurse? 1. "It's okay. Let's talk about this." 2. "Have you discussed this with your primary healthcare provider?" 3. "Can you tell me how you feel about what happened?" 4. "Tell me more about what happened when you were younger."

3. "Can you tell me how you feel about what happened?" (3. Correct: The nurse is using a therapeutic approach by encouraging the client to express feelings about the relationship using an open-ended question. 1. Incorrect: The nurse is providing false reassurance by saying, "It's okay." This is a statement not a question to see how the client feels about talking with the nurse. The nurse should use open-ended questions to determine whether or not the client wishes to discuss the incestuous relationship further at this time. 2. Incorrect: This is a non-therapeutic, closed ended question that only requires a yes or no answer. This is not a priority at this time. An open ended question will allow the nurse to see if the client is ready to share with the nurse. 4. Incorrect: The nurse should not probe for a factual account about a past event and should keep the focus of the discussion on the client's feelings about the event. Again, this is a statement, not an open ended question.)

A client arrives at the crisis center and reports stopping daily lithium because of pregnancy. What response by the nurse is most accurate? 1. "Are you positive that you are actually pregnant?" 2. "Lithium is perfectly safe throughout pregnancy." 3. "The psychiatrist can change you to another medication that is safe." 4. "It may be worse to suddenly stop the medication than to take the medication."

4. "It may be worse to suddenly stop the medication than to take the medication." (4. Correct: Lithium is most often used to treat manic-depression. Suddenly stopping the medication could cause the client to relapse, experiencing worse symptoms than previously. It may also be more difficult to get those symptoms under control again if the client has stopped this drug suddenly. The client and primary healthcare provider would need to weigh the benefits of the medication vs the possible birth defects attributed to the use of lithium during pregnancy. 1. Incorrect: While this is a valid question by the nurse, there is a greater concern at this point. The client's pregnancy status can be verified at any time. 2. Incorrect: This statement by the nurse is not correct. Specific birth defects have been attributed to the use of lithium during pregnancy. 3. Incorrect: The psychiatrist would need to be notified that client has stopped the medication. However, there are very few medications for bipolar disorder that would also be completely safe during pregnancy.)

The nurse is caring for a client who is severely depressed and has an extremely low energy level. The client answers questions by using one or two words, and makes no eye contact. Which intervention is most appropriate for this client? 1. Ask the client to go to the group session with you. 2. Remind the client to interact with the nurse today. 3. Sit with the client and make no demands. 4. Allow the client to decide when to talk with the nurse.

3. Sit with the client and make no demands. (3. Correct: The client is severely depressed and does not wish to have one on one interaction. Sitting with the client without demands demonstrates that the client is worthy of your time. The silence may also encourage the client to talk with you. 1. Incorrect: The client's energy level is low, so the client would not respond positively to this request. Depressed clients may speak slowly and have slowed comprehension. Group therapy would not be appropriate at this time. 2. Incorrect: The client may not have adequate energy for spontaneous interaction today. Also, reminding the client to interact is not therapeutic. The client may view this as the nurse thinking they are worthless. 4. Incorrect: When clients are extremely depressed, they cannot make decisions independently. Extreme fatigue interferes with social activities and relationships.)

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. The client is being taught self-advocacy. (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. 1. Incorrect: This maybe true; however, it does not serve the best rationale for this client. Specifically this client needs assertiveness to assist their return to employment and home environment. 2. Incorrect: This statement is maybe true; however, it does not serve as an accurate rationale assertiveness training. 4. Incorrect: No the person should not be manipulated by an employer; however, the rationale in this question is to teach the client self advocacy through assertiveness training.)

A client who was diagnosed with paranoid delusions has been prescribed a chest x-ray. The client refuses the chest x-ray and states "No, they want to kill me with the rays from the x-ray machine." Which nursing response is appropriate? 1. "Do you think people want to kill you with rays?" 2. "You don't have to worry that someone is going to kill you." 3. "I don't want you to talk about the x-ray technicians." 4. "Where did you get the idea that someone was trying to kill you?"

1. "Do you think people want to kill you with rays?" (1. Correct: By restating the client's primary idea this reinforces to the client that statement has been heard. This allows the client to clarify the statement or realize that the nurse has understood the comment. This is the therapeutic communication technique of restating. 2. Incorrect: The nurse is using the nontherapeutic communication technique of giving reassurance. The nurse is stating that the client has nothing to worry about. The client may feel the nurse is moderating their intense concern of the possibility of being killed. 3. Incorrect: The nurse is disregarding the client's concern about possibly being killed. The nurse is redirecting the conversation about the client to concern for the x-ray technicians. The nurse is preferring the conversation to be focused on another topic. This is an example of the nontherapeutic communication technique of introducing an unrelated topic. 4. Incorrect: Demanding a reason from the client about their thoughts or feelings is an example of the nontherapeutic communication technique of requesting an explanation. This is a direct question. The client will need to defend their feelings or thought. The client may feel intimidated and stop communicating with the nurse.)

A client being treated in the intensive care unit following methamphetamine intoxication states, "Snakes are crawling all over the room, get me out of here!" How does the nurse document this assessment finding? 1. Delusions 2. Hallucinations 3. Flashbacks 4. Depersonalization

2. Hallucinations (2. Correct: Hallucinations are false sensory perceptions 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. 1. Incorrect: Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background. These beliefs are not consistent with reality. Often the client will either feel all powerful or have extreme unrealistic fears. 3. Incorrect: Flashbacks are a spontaneous recurrence of the hallucinogenic state without ingestion of the drug. These can occur months after the drug has been taken. 4. Incorrect: Depersonalization can occur, but it is the observation of oneself having an experience. The client may report feelings of being an outside observer of their own thoughts or body with a sense of loss of control. This is sometimes described as an out-of-body experience for the client.)

The nurse is caring for a client diagnosed with major depression post electroconvulsive therapy (ECT). What nursing interventions should be included in this immediate post-treatment period? Select all that apply 1. Monitor vital signs every hour for eight hours. 2. Position the client on their side. 3. Stay with the client until fully awake. 4. Provide flexibility in scheduling routine activities. 5. Encourage the client to ambulate in room and hall.

2. Position the client on their side. 3. Stay with the client until fully awake. (2. & 3. Correct: Positioning on the side will prevent aspiration. Stay with the client until they are fully awake, oriented, and able to perform self-care activities without assistance. Safety is priority. 1. Incorrect: Pulse, respirations, and blood pressure should be monitored every 15 minutes for the first hour. Vital signs every hour are too long immediately post-treatment. 4. Incorrect: The client needs a highly structured schedule of routine activities in order to minimize confusion. Also, immediately post-treatment is too soon to address routine activities. 5. Incorrect: The client should remain in bed during the immediate post-treatment period. The client needs to be fully awake prior to ambulation.)

In the office for a yearly physical examination, a 30-year-old client reports that the client and husband used to be very happy before the children were born. Now the client is struggling with the current situation. What should the nurse understand about this situation? 1. The client is probably having an extramarital affair. 2. The developmental task at this stage is adjusting to the needs of more than two family members. 3. A relative or close friend should be consulted for help so the client can pursue activities outside the home. 4. The client should be referred to a psychotherapist for evaluation and care.

2. The developmental task at this stage is adjusting to the needs of more than two family members. (2. Correct: When children are born or adopted into a family, the established couple must adjust to supporting the physical and emotional needs of the additional family member. Additionally, the couple is engaged in developing an attachment with the child(ren) and coping with energy depletion and lack of privacy. These requirements may lead to a sense of unhappiness and frustration on the part of one or both parents. 1. Incorrect: The answer choice that the client is having an extramarital affair is inappropriate. There is no evidence to support this assumption. 3. Incorrect: Although receiving assistance from family and friends is a good option, it is not the best answer choice. This family has to learn to adjust to being a family. 4. Incorrect: The client's feelings are normal and do not require that the client be referred to a psychotherapist.)

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. Utilize client's own strengths to increase self-esteem. (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. 1. Incorrect: The process of treating a client for severe depression utilizes multiple therapeutic techniques, including possible medications, and interactive communication. However, distracting the client instead of talking through emotions is not the purpose of painting. 2. Incorrect: A client diagnosed with depression tends to withdraw from social interactions, particularly in groups. Instructing a small group of individuals may require the client to communicate but this activity is not specifically for that purpose. 4. Incorrect: While it is crucial to establish a trusting relationship with the client, the suggested painting activity is not for that purpose.)

A client is being cared for in the intensive care unit following a traumatic amputation of the left lower arm. As the nurse enters the room for a routine check, the client begins to cry and states "This is so overwhelming." What statement by the nurse would be most appropriate at this time? 1. "You have been through a lot, but look on the bright side; you are doing better now." 2. "Try to be optimistic. You are going to be fitted for a prosthesis once you are healed." 3. "I understand that you are upset, but crying is not going to help your situation." 4. "This must be very difficult for you. What seems to be the hardest part for you now?"

4. "This must be very difficult for you. What seems to be the hardest part for you now?" (4. Correct: This client has experienced a very significant personal loss and can go through the grieving process, similar to those who experience the death of a loved one. The nurse should be very sensitive to the feelings of loss being felt by this client due to the loss of a body part. This client is reporting feeling overwhelmed. The best way for the nurse to respond to this client's feelings would be to first acknowledge that the situation must be very difficult for the client. The nurse can further explore this by asking what seems to be the hardest part for the client currently. This will guide the nurse with how to best assist the client at the current time and meet the most immediate emotional needs of this client. By addressing what is most overwhelming at the present time, the nurse can more effectively assist the client in gradually working through the grief process and dealing with the loss. 1. Incorrect: The nurse's comment starts out with an acceptable comment of acknowledging that the client has been through a lot but then immediately negates the client's feelings of being overwhelmed by telling the client to look on the bright side and that the client is doing better now. This statement discounts the client's feelings of loss and being overwhelmed with all that it entails. 2. Incorrect: This comment by the nurse that tells the client to be optimistic because a prosthesis will be fitted does not address the client's current feelings. This is a total disregard to the overwhelming feelings of loss that the client is experiencing. As the client works through the feelings of loss over time, the nurse can help provide a sense of hope and optimism about the use of a prosthesis, but the client's current feelings should be addressed first. 3. Incorrect: Again, the nurse's comment about recognizing that the client is upset could be appropriate, but the comment following this about crying not helping the situation could cause the client to feel belittled and may actually cause the client to become bitter or reluctant to share true feelings with the nurse. The nurse should support the client and explore how to best help the client work through these feelings of extreme loss.)

The nurse is caring for a client diagnosed with Obsessive Compulsive Disorder (OCD). Which statement, made by the client, would be the best indicator of improvement? 1. "My friends don't know I have OCD." 2. "I only do my hand washing to reward myself when I am good." 3. "I know my thoughts and behaviors aren't very normal." 4. "I have more control over my thoughts and behaviors."

4. "I have more control over my thoughts and behaviors." (4. Correct: Control is an issue for those with OCD. Appropriate goals for this client would be to control unwanted behaviors and thoughts. 1. Incorrect: Doesn't indicate control over behavior. Not telling their friends indicates the client is ashamed of disease and doesn't show improvement. 2. Incorrect: The behaviors are not reward for good behavior; they are utilized to decrease anxiety. Compulsions are ritualistic behavior that the individual feels driven to perform in an attempt to reduce anxiety. 3. Incorrect: Clients with OCD are aware their behavior is not normal, so this would not be an indicator of improvement. Obsessions are defined as thoughts, impulses or images that persist and recur, so that they cannot be dismissed from the mind.)

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. Clients can receive and send mail, but staff must check for hazards. (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. 2. Incorrect: This statement indicates lack of understanding of client's rights. This includes the right to send and receive "sealed, unopened, uncensored mail." If the client is present, staff may open and check mail for contraband, but may not read it. The superintendent, director, or designee of the superintendent or director must document with specific facts the reason for opening the mail. 3. Incorrect: This statement indicates lack of understanding of client's rights on the mental health unit. 4. Incorrect: The client has a right to send and receive mail throughout their hospital stay.)

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? Select all that apply 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. Upon death, close the eyelids and mouth and pull a covering over the body. 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. 2. Incorrect: Cremation is strictly forbidden in the Islamic faith. 3. Incorrect: Islamic practices call for burying the body as soon as possible, which eliminates the need for embalming, unless required by law. However, taking the body to the morgue immediately would not allow the family time to perform the washing and enshrouding of the body and would be disrespectful to both the deceased and the family. In addition, autopsies are not usually allowed unless there is foul play suspected, in which permission may be granted to perform the autopsy. The body of the deceased should be disturbed as little as possible after death.)

The client, who recently started college, tells the nurse, "I am having trouble studying for my tests. Every time I try to study, my mind begins to wander." What is the nurse's best response? 1. "Stop making excuses and make a study schedule you will follow." 2. "I wouldn't worry. You are smart enough to pass college." 3. "You are having difficulty concentrating?" 4. "What do you mean you can't study?"

3. "You are having difficulty concentrating?" (3. Correct: The correct answer demonstrates the therapeutic communication technique of "restating". The main idea is to let the client know whether or not an expressed statement has been understood and gives him or her the chance to continue or clarify if necessary. 1. Incorrect: This response is disapproving and gives advice. It is not therapeutic. The nurse does not know the client is making excuses and should not assume. 2. Incorrect: This response is giving reassurance. This statement seems like the nurse is somewhat "blowing off" the client. It does not address this issue. 4. Incorrect: This response is belittling. This statement does not address the client's problem. It also implies that the client should not have problems studying.)

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. "Though it is difficult, the staff needs to remain relaxed, but conscious of the client's violent episodes." (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. 1. Incorrect: The charge nurse is concluding the meaning of what the new nurse is saying. This is an example of the nontherapeutic communication of interpreting. The charge nurse stated that the new nurse is scared. This response may block further discussions with the new nurse about nursing care for potentially violent clients. The client, other clients, and the healthcare team's safety can also be placed at risk. 3. Incorrect: The charge nurse is changing the subject by stating that the staff members will be directed to monitor the client for violent behavior. This nontherapeutic communication of introducing an unrelated topic allows the charge nurse to control the direction of the conversation. The new nurse is expressing her concerns about caring for a client with violent episodes. The charge nurse is not focusing on the concerns of the new nurse. 4. Incorrect: The charge nurse responds by stating the new nurse attended an in-service during orientation about dealing with a client with violent behavior. The charge nurse does not identify that the new nurse may be uncomfortable dealing with clients with violent behavior. This is the nontherapeutic communication technique of rejecting. The new nurse may stop sharing with the charge nurse because of concern over further rejection.)

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. Flosses teeth five times after each meal. (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. 1. Incorrect: Though there is no indication of the number of doors in the hallway, it is possible that repeated knocking might cause skin abrasions and breakdown on the knuckles. The nurse might suggest wearing gloves, or even limiting the knocking to specific doors. However, this ritual is not the nurse's greatest concern. 3. Incorrect: Washing hands three times before every meal could certainly cause some skin excoriation; however, it is not the most injurious action the client is completing. Using a mild soap and applying cream after this routine could alleviate potential skin breakdown. 4. Incorrect: Brushing hair was previously considered a positive daily treatment for hair, and even vigorous brushing twice a day is unlikely to create serious problems for the client. The nurse would not be primarily concerned about this activity.)

The client with obsessive-compulsive disorder (OCD) asks the nurse for help with a repetitive behavior. What is the most likely origin of this behavior? 1. Fear 2. Depression 3. Delusions 4. Anxiety

4. Anxiety (4. Correct: Yes, this is how they deal with anxiety. The obsession causes the anxiety such as a thought that can't be dismissed from the mind. The ritualistic behavior that the client is driven to perform is an attempt to reduce anxiety. The compulsive act temporarily reduces high levels of anxiety. 1. Incorrect: No, is phobia that deals with fears. A phobia is an excessive and irrational fear reaction. If you have a phobia you may experience a deep sense of dread or panic when you encounter the source of your fear. 2. Incorrect: OCD is not about depression. Depression is a mood disorder that causes persistent feelings of sadness and loss of interest. Not the origin of OCD. 3. Incorrect: Delusions are not associated with OCD. Delusions are most often defined as false fixed beliefs that cannot be corrected by reasoning.)

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. "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. 1. Incorrect: Telling grieving family members not to cry is certainly not very therapeutic. They need to feel free to express their emotions of grief at the time of impending death of the loved one. This statement would be a barrier to demonstrating care and concern. 2. Incorrect: Telling the family that things will be fine and to give themselves time are trite assurances and clichés that should be avoided by the nurse. Instead, you should use therapeutic responses that promote the expressions of grief by the family. 3. Incorrect: Again, by telling them to try not being upset in front of the dying family member, this is not demonstrating care and compassion to the family members who are grieving. This would be a barrier to assisting them to communicate and express their feelings of grief.)

A psychiatric client tells the day shift nurse, "The night nurses have been stealing from all of us while we are sleeping." What is the nurse's best response? 1. "Can you prove what the nurses are stealing?" 2. "No nurse working here would steal." 3. "You must have misunderstood what you were seeing." 4. "Tell me more about what you saw."

4. "Tell me more about what you saw." (4. Correct: This open ended question allows for exploring the idea the client has. This statement does not accuse anyone or deny the possibility of stealing. This statement allows the nurse to remain nonthreatening and nonjudgmental. 1. Incorrect: This response shows disapproval. This statement could make the client feel uncomfortable and seem like the nurse is taking the side of the other nurses. 2. Incorrect: This response is disagreeing with the client. This is a closed-ended statement that does not allow the client to discuss this topic further. Since the nurse has said no nurse would steal then the client most likely will become defensive. 3. Incorrect: This response is defending. It also makes the client feel that the nurse does not believe them.)

The nurse is reviewing a safety contract with a client who is suicidal. However, the client declines to sign the safety contract at this time. What action must the nurse take? 1. Check that all windows are locked and the doors secured. 2. Secure the room by removing potentially harmful objects. 3. Place client in a chair at nursing station until contract is signed. 4. Assign a staff member to stay with client, even in the bathroom.

4. Assign a staff member to stay with client, even in the bathroom. (4. Correct: A safety contract states the client will not do any self-harm in a specified length of time or without calling the nurse. If there is a refusal to sign such a contract, the client cannot be alone even when using the bathroom. Safety is always the priority concern for a suicidal client. 1. Incorrect: Although facilities have specific safety precautions for doors and windows, it violates fire safety codes to lock exits. There is no indication this is a psychiatric facility but safety regulations apply to all client facilities. 2. Incorrect: It is impossible to "secure" any room completely. If a client wishes to bring self-harm, any object can become lethal, even a soft pillow. 3. Incorrect: Placing a client in a chair for an unspecified length of time is punitive and verges on abuse. This client may never sign a safety contract. Also, the chaos of the nursing station could further upset the client.)

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. 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. 1. Incorrect: While it is true that a component of PTSD treatment involves either antianxiety or antidepressant medications, these drugs take several weeks to become effective. The nurse needs to provide an intervention that will give the client more immediate relief. 2. Incorrect: Clients with PTSD generally do benefit from family support and interaction, especially during periods of increased symptoms. However, the question requests a nursing action that would assist the client in crisis now. 3. Incorrect: Support groups are always beneficial for individuals experiencing long term problems, and are an invaluable resource to both client and family members. However, this question asks how the Crisis Center nurse could intervene to assist at this moment. This choice is a long term solution.)

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. 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. 1. Incorrect: This type of comment indicates concrete thought. Concrete thinking is characterized by immediate experience rather than abstraction. 2. Incorrect: This type of comment indicates circumstantiality. This is characterized by indirectness and delay before the person gets to the point or answers a question. The person gets caught up in countless details and explanations. 3. Incorrect: These indicate loose associations or derailment. It is a sequence of unrelated or only remotely related ideas.)