NUR 114 test 4

a. the client described is at highest risk for impaired social isolation

A nurse is caring for a 42-year-old unmarried client with a history of depression and OCD who presents to the clinic for a rash on his hands from excessive ritualistic handwashing. The client recently lost his job because he didn't fit in. he is considering moving in with his mom and does not participate in outside activities or engage in exercise. Based on the information provided was nursing diagnosis is the client at highest risk for? a. social isolation b. risk prone behavior c. disturbed personal identity d. ineffective tissue perfusion

b secondary suicide prevention aims to decrease the likelihood of a suicide attempt in high-risk clients

a charge nurse is providing an inservice about suicide interventions. which of the following should the nurse include as an example of a secondary intervention? a. provide support to surviving family members following a suicide b. identifying individuals who are at higher risk c. attempts to diminish suicide contagion and copy cat suicides d. attempts to reduce the number of new suicides in the general population

a When an SSRI is prescribed for clients diagnosed with bipolar disorder it can cause alterations in neurotransmitters and trigger hypomanic or manic episode

a client admitted after experiencing suicidal ideations is prescribed citalopram (celexa). 4 days later the client has pressured speech and is noted wearing heavy makeup. what may be a potential reason for this clients behavior? a. the client has a manic episode caused by the celexa b. the client is showing improvement and is close to discharge c. the client is masking depression in an attempt to get out of the hospital d. the client has 'cheeked' medications and taken them all in an attempt to overodse

b Numerous physical conditions can contribute to symptoms of insomnia including irritability, anorexia and depressed mood. It is important for the nurse to rule out this physical problems before assuming that the symptoms are psychological in nature. The nurse can do this by completing a thorough physical assessment including review of lab test

a client denying suicidal ideations comes into the ED complaining about insomnia, irritability, anorexia and depressed mood. which intervention would the nurse implement first? a. request a psych consult b. complete a thorough physical assessment including lab tests c. remove all hazardous materials from the environment d. place the client on a one to one observation

d Xanax is the CNS depressant and it is important for the nurse in the situation to monitor for worsening depressive symptoms and possible worsening of suicidal ideation's

a client diagnosed with MDD and experiencing suicidal ideation is showing signs of anxiety. alpralozam (xanax) is prescribed. which assessment should be prioritized? a. monitor for s/s of physical and psychological withdrawal b. teach the client about side effects of the medication and how to handle these side effects c. assess for nausea and give the medication with food if nausea occurs d. ask the client to rate his or her mood on a mood scale and monitor for suicidal ideations

b It is important for the client to learn techniques to reduce overall levels of anxiety to decrease the need for compulsive behaviors. The teaching of these techniques should begin by day four

a client diagnosed with OCD has been hospitalized fo the past 4 days. which intervention would be a priority at this time? a. notify the client of the expected limitations on compulsive behaviors b. reinforce the use of learned relaxation techniques c. allow the client the time needed to complete the compulsive behaviors d. say 'stop' to the client as a thought stopping technique

b Excessive worrying about germs and illness is a cognitive symptom experience by clients diagnosed with OCD

a client diagnosed with OCD is newly admitted to an inpatient psych unit. which cognitive symptom would the nurse expect to assess? a. compulsive behaviors that occupy more than 4 hours per day b. excessive worrying about germs and illness c. comorbid abuse of alcohol to decrease anxiety d. excessive sweating and an increase in BP and pulse

B Any client who is exhibiting hopelessness or helplessness needs to be monitored closely for suicide intentions

a client diagnosed with panic attacks is being admitted for the 5th time in 1 year because of hopelessness and homelessness. which precaution would the nurse plan to implement? a. elopement precautions b. suicide precautions c. homicide precautions d. fall precautions

d If a client comes into the inpatient psych unit with a plan to overdose it is critical that the nurse monitor for cheeking and hoarding of medications. Clients may cheek and hoard medications to take as an overdose at another time

a client experiencing suicidal ideations with a plan to overdose on medications is admitted to the inpatient psych unit. vilazodone (viibryd) is prescribed. which nursing intervention takes priority? a. remind the client that medication effectiveness may take 2-3 weeks b. teach the client to take the medication with food to avoid nausea c. check the clients BP every shift to monitor for HTN d. monitor closely for signs that the client might be 'cheeking' the medication

a Remaining free from injuries or a hospitalization is a priority outcome for the nursing diagnosis of risk for suicide related to a pastor side of town. Because this outcome addresses client safety it is prioritized

a client has a nursing diagnosis of risk for suicide r/t a past suicide attempt. which outcome based on this diagnosis would the nurse prioritize? a. the client will remain free from injury throughout hospitalization b. the client will set on realistic goal related to relationships by day 3 c. the client will verbalize on positive attribute about self by day 4 d. the client will be easily redirected when discussion about suicide occurs by day 5

c Hanging is a serious suicide attempt. The plan of care must reflect action that ensures the client safety. A constant observation status with the staff member is the best choice. Placing the client in a hospital gown and requesting that appear remain with the client would not ensure a safe environment. Seclusion should not be the initial intervention in the least restrictive measures should be used

a client is admitted to the mental health unit after an attempted suicide by hanging. the nurse can best ensure client safety by which action? a. requesting that a peer remain with the client at all times b. removing the clients clothing and placing the client in a hospital gown c. assigning to the client a staff member who will remain with the client at all times d. admitting the client to a seclusion room where all potentially dangerous articles are removed

a Using excessive handwashing to relieve anxiety is a behavioral symptoms exhibited by clients diagnosed with OCD

a client newly admitted to the inpatient psych unit is diagnosed with OCD. which behavioral symptom would the nurse expect to assess? a. the client uses excessive hand washing to relieve anxiety b. the client rates anxiety 8/10 c. the client uses breathing techniques to decrease anxiety d. the client exhibits diaphoresis and tachycardia

d By day four it would be realistic to expect the client to use one relaxation technique to decrease obsessive or compulsive behaviors. This would be the current priority outcome

a client was admitted to an inpatient psych unit 4 days ago for the treatment of OCD. which outcome takes priority for this client at this time? a. the client will use a thought stopping technique to eliminate obsessive and/or compulsive behaviors b. the client will stop obsessive and/or compulsive behaviors in order to focus on ADLs c. the client will seek assistance from the staff to decrease obsessive and/or compulsive behaviors d. the client will use one relaxation technique to decrease obsessive and/or compulsive behaviors

d clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The nurse should ask the client directly whether a plan for self harm exists

a depressed client on an inpatient unit says to the nurse, 'my family would be better off without me.' which is the nurses best response? a. 'have you talked to your family about this?' b. 'everyone feels this way when they are depressed' c. 'you will feel better once your medication begins to work' d. 'you sound upset. are you thinking of hurting yourself?'

c Risk for suicide related to history of attempts is a priority nursing diagnosis for a client who is diagnosed with MDD and has a history of two suicide attempts by hanging. History of a suicide attempt increases a clients risk for future attempts. Because various means can be used to hang on self the client is at risk for accessing these means even on an inpatient unit. These factors would cause the nurse to prioritize the safety concern

a newly admitted client diagnosed with MDD has a history of two suicide attempts by hanging. which nursing diagnosis takes priority? a. risk for violence directed at others r/t anger toward another b. social isolation r/t depressed mood c. risk for suicide r/t history of suicide attempts d. hopelessness r/t multiple suicide attempts

d Risk for self directed violence is the priority diagnosis for a newly admitted client diagnosed with MDD. Risk for self directed violence is defined as behaviors in which the individual demonstrates that he or she can be physically harmful to self. This is a life-threatening problem that requires immediate prioritization by the nurse

a newly admitted client has been diagnosed with MDD. which nursing diagnosis takes priority? a. social isolation r/t poor mood AEB refusing visits from family b. self care deficit r/t hopelessnessAEB not taking a bath for 2 weeks c. anxiety r/t hospitalization AEB anxiety rating 8/10 d. risk for self directed violence r/t depressed mood

a, c, e

a nurse is assessing a client who has MDD. the nurse should identify which of the following client statements as an overt comment about suicide? select all that apply a. 'my family will be better off if im dead' b. 'the stress in my life is too much to handle' c. 'i wish my life was over' d. 'if i dont feel like i can ever be happy again' e. 'if i kill myself then my problems will go away'

a washing her hands helps lower the anxiety that comes along with OCD

a nurse is assessing a client who has OCD and repetitively washes her hands. the nurse should recognize that this behavior is an attempt to accomplish which of the following? a. decrease anxiety b. prevent aggressive and impulsive behaviors c. manipulate others d. limit dissociative reactions

a, c, e

a nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. which of the following interventions should the nurse include as a primary intervention? select all that apply a. conducting a suicide risk screening on all new clients b. creating a support group for family members of clients who completed suicide c. educating high school teens about suicide prevention d. initiating one on one observation for a client who has concurrent suicidal ideations e. teaching middle school educators about warning indications of suicide

d clients with OCD have compulsions that make them do things to decrease their anxiety

a nurse is caring for a client who has OCD and is constantly reorganizing books on a shelf in the dayroom. the nurse should recognize that the client uses this behavior to do which of the following? a. limit dissociative reactions to stressful stimuli b. focus attention on meaningful tasks c. manipulate and control others behaviors d. decrease anxiety to a tolerable level

d

a nurse is caring for a client who is on suicide precautions. which of the following interventions should the nurse include in the plan of care? a. assign the client to a private room b. document the clients behavior every hour c. allow the client to keep perfume in her room d. ensure that the client swallows medication

b

a nurse is caring for a client who states, 'i plan to commit suicide.' which of the following assessments should the nurse identify as the priority? a. clients educational and economic background b. lethality of the method and availability of means c. quality of the clients social support d. clients insight into the reasons for the decision

d

a nurse is conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. which of the following information should the nurse include in the teaching? a. a clients verbal threat of suicide is attention seeking behavior b. interventions are ineffective for clients who really want to commit suicide c. using the term suicide increases the clients risk for a suicide attempt d. a no-suicide contract decreases the clients risk for suicide

d A client admitted six days ago for suicidal ideation has begun to stabilize because of the treatment received during this time frame. Compared with the other clients describe this client would have the highest level of readiness to participate in instruction

a nurse is planning to teach about appropriate coping skills. the nurse would expect which client to be at highest level or readiness to participate in this instruction? a. a newly admitted client with an anxiety level of 8/10 and racing thoughts b. a client admitted 6 days ago fro a manic episode refusing to take medications c. a newly admitted client experiencing suicidal ideations with a plan to overdose d. a client admitted 6 days ago for suicidal ideations following a depressive episode

c inspecting the belongings is a way to ensure there is no harmful objects that the client can potentially use

a nurse is teaching a group of newly licensed nurses about suicide precautions. which of the following interventions should the nurse include in the teaching? a. include metal utensils with the clients meal tray b. assign the client to a private room c. inspect the clients personal belongings d. keep the clients door closed at all times

a this medication can cause photosensitivity so wearing sunscreen and protective clothing is important to teach

a nurse is teaching an adolescent client who has a new prescription for fluoxetine to treat OCD. which statement should the nurse include in the teaching? a. 'wear sunscreen when outdoors' b. 'check your daily weight' c. 'take the medication at bedtime' d. 'the effects of this medication are immediate'

c ritualistic behaviors are performed to reduce anxiety

a nurse manager is teaching a group of staff nurses about the purpose of ritualistic behaviors for clients who have OCD. which of the following statements by the staff nurse indicates an understanding of the teaching? a. 'ritualistic behaviors provide sexual satisfaction' b. 'clients perform ritualistic behaviors to boost self confidence' c. 'ritualistic behaviors temporarily relieve anxiety' d. 'clients perform ritualistic behaviors that are directly related to the stressor'

a the greatest risk to this client is self harm. there this action takes priority

a nurse working on an acute mental health unit is caring for a client who states he has thoughts of suicide. which of the following actions should the nurse take first? a. monitor the client for the risk of self harm b. ensure the client takes prescribed medications c. encourage the client to express feelings d. assist the client to develop a safety plan

b Almost 95% of all individuals who commit or attempt suicide have a diagnosed mental disorder. Most suicides are associated with mood disorders

a nursing instructor is presenting statistics regarding suicide. which student statement indicated that learning has occurred? a. approximately 10,000 individuals in the US will commit suicide each year b. almost 95% of all individuals who commit or attempt suicide have a diagnosed mental disorder c. suicide is the 8th leading cause of death among young americans 15-24 ears old d. depressive disorders account for 1/3 of all individuals who commit or attempt suicide

a adolescents can copycat suicide if a peer or significant role model has recently committed suicide.

a school nurse is speaking to a 16 year old male adolescent. which of the following client statements should indicate that the client is at risk for suicide? a. 'my favorite teacher committed suicide a few weeks ago' b. 'ive recently organized and lead a conflict resolution team here at school' c. 'i attend religious services twice a week' d. 'i spend most of my time with my two best friends'

a In the Jewish faith the seven day period beginning with the burial is called Shiva. During this time warner do not work and no activity is permitted that diverts attention from thinking about the deceased. Because its clients parent died two days ago the client needs time to participate in this religious ritual

a suicidal jewish american client is admitted to an inpatient psych unit 2 days after the death of a parent. which intervention must the nurse include in the care of this client? a. allow the client time to mourn the loss during this time of shiva b. distract the client from the loss and encourage participation in unit groups c. teach the client alternative coping skills to deal with grief d. discuss positive aspects the client has in his or her life to build on strengths

c Undoing is a defense mechanism commonly used by individuals diagnosed with OCD. Undoing is used Symbolically to negate or cancel out an intolerable previous action or experience. An individual diagnosed with OCD experiencing intolerable anxiety would use the defense mechanism of undoing to undo this anxiety by substituting obsessions or compulsions Or both. Other commonly use defense mechanisms are isolation, displacement, and reaction formation

clients diagnosed with OCD commonly use which defense mechanism? a. suppression b. repression c. undoing d. denial

b It is important for the nurse to ask the client about potential plan for suicide in order to evaluate the clients intentions and safety risk. This knowledge for direct appropriate and timely nursing interventions. Clients have developed suicidal plans are at higher risk than clients who may have vague suicidal thoughts

during an intake assessment a client diagnosed with generalized anxiety disorder rates mood 3/10, rates anxiety at 8/10 and states, 'im thinking about suicide.' which nursing intervention takes priority? a. teach the client relaxation techniques b. ask the client, 'do you have a plan to commit suicide?' c. call the physician to obtain a PRN order for an anxiolytic medication d. encourage the client to participate in group activities

a A long history of low fiber high fat and high protein diet results in a prolonged transit time. This allows the carcinogenic agents in the waste products to have a greater exposure to the lumen of the colon

the 85 year old male client diagnosed with cancer of the colon asks the nurse, 'why did i get this cancer?' which statement is the nurses best response? a. 'research shows a lack of fiber in the diet can cause colon cancer' b. 'it is not common to get colon cancer at your age, it is usually in young people' c. 'no one knows why anyone gets cancer, it just happens to certain people' d. 'women usually get colon cancer more often that men but not always'

b The nurse should determine what is concerning the client. It could be a misunderstanding or real situation where the clients care is unsafe or in adequate

the client complains to the nurse of unhappiness with the HCP. which intervention should the nurse implement first? a. call the HCP and suggest he or she talk with the client b. determine what about the HCP is bothering the client c. notify the nursing supervisor to arrange a new HCP to take over d. explain the client cannot request another HCP until after discharge

c This diet has an intestinal blockage from a solid tumor block in the colon. Although the client needs to be cleaned out for the colonoscopy goLYTELY could cause severe cramping without a reasonable benefit to the client and could cause a medical emergency

the client presents with a complete blockage of the large intestine from a tumor. which HCP order would the nurse question? a. obtain consent for colonoscopy and biopsy b. start an IV of NS at 125 mL/hr c. administer 3 liters of goLYTELY d. give tap water enemas until it is clear

d The power should be emptied when it is 1/3 to 1/2 full To prevent the contents from becoming too heavy for the seal to hold and to prevent leakage from occurring

the client who has had an abdominal perineal resection is being discharged. which discharge information should the nurse teach? a. the stoma should be white, blue, or purple color b. limit ambulation to prevent the pouch from coming off c. take pain medication when the pain level is at an 8 d. empty the pouch when it is one third to one half full

b The client should be on a regular diet and the colostomy will have been working for several days prior to discharge. The client statement indicates the need for further teaching

the client with a new colostomy is being discharged. which statement made by the client indicates the need for further client? a. 'if i notice any skin breakdown i will call the HCP' b. 'i should drink only liquids until the colostomy starts to work' c. 'i should not take a tub bath until the HCP okays it' d. 'i should not drive or lift more than 5 pounds'

a The nurse should mark the drainage on the dressing to determine if active bleeding is occurring because dark reddish brown drainage indicates old blood. This allows the nurse to assess what is actually happening

the nurse caring for a client 1 day post op sigmoid resection notes a moderate amount of dark reddish brown drainage on the midline abdominal incision. which intervention should the nurse implement first? a. mark the drainage on the dressing with the time and date b. change the dressing immediately using sterile technique c. notify the HCP immediately d. reinforce the dressing with a sterile gauze pad

a, c, b, d

the nurse in the ED is assessing a client suspected of being suicidal. number the following assessment questions beginning with the most critical and ending with the least critical. a. 'are you currently thinking about suicide?' b. 'do you have a gun in your possession?' c. 'do you have a plan to commit suicide?' d. 'do you live alone? do you have local friends or family?'

c The most common symptom of colon cancer is a change in bowel habits specifically diarrhea alternating with constipation

the nurse is admitting a client to a medical floor with a diagnosis of adenocarcinoma of the rectosigmoid colon. which assessment data support this diagnosis? a. the client reports up to 20 bloody stools per day b. the client has a feeling of fullness after a heavy meal c. a the client has diarrhea alternating with constipation d. the client complains of right lower quadrant pain

c The American Cancer Society recommends a colonoscopy at age 50 and every 5 to 10 years there after and a flexible sigmoidoscopy and a barium enema every five years

the nurse is caring for client in an outpatient clinic. which information should the nurse teach regarding the american cancer societys recommendations for the early detection of colon cancer? a. beginning at age 60 a digital rectal exam should be done yearly b. after reaching middle age a yearly fecal occult blood test should be done c. have a colonoscopy at age 50 and then once every 5-10 years d. a flexible sigmoidoscopy should be done yearly after age 40

a 1 to 1 suicide precautions are required for a client who has attempted suicide. Options two and three may be appropriate but not at the present time considering the situation. Option four also may be appropriate but the priority is identified in the correct option. The best intervention is constant supervision so that the nurse may intervene as needed if the client attempts to harm herself or himself

the nurse is planning care for a client being admitted to the nursing unit who attempted suicide. which priority nursing intervention should the nurse include in the plan of care? a. one to one suicide precautions b. suicide precautions with 30 minute checks c. checking the whereabouts of the client every 15 minutes d. asking the client to report suicidal thoughts immediately

a, c, e

the nurse is planning care for a client who has had an abdominal perineal resection for cancer of the colon. which interventions should the nurse implement? select all that apply a. provide meticulous skin care to stoma b. assess the flank incision c. maintain the indwelling catheter d. irrigate the JP drains every shift e. position the client semirecumbent

a, b, e

the nurse on the inpatient psych unit should include which of the following interventions when working with a newly admitted client diagnosed with OCD? select all that apply a. assess previously used coping mechanisms and their effects on anxiety b. allow time for the client to complete compulsions c. with the clients input set limits on ritualistic behaviors d. present the reality of the impact that the compulsions have on the clients life e. discuss clients feelings surrounding the obsessions and compulsions

d A pouch that becomes dislodged during the sexual act would cause embarrassment for the client whose body image has already been dealt a blow

the nurse writes a psychosocial problem of risk for altered sexual function related to new colostomy. which interventions should the nurse implement? a. tell the client there should be no intimacy for atleast 3 months b. ensure the client and significant other are able to change the ostomy pouch c. demonstrate with charts possible sexual positions for the client to assume d. teach the client to protect the pouch from being dislodged during sex

b Cruciferous vegetables such as broccoli cauliflower and cabbage are high in fiber. What are the risk for cancer of the colon is a high fat low fiber and high-protein diet. The longer the transit time the greater the chance of developing cancer of the colon

the occupational health nurse is preparing a presentation to a group of factory workers about preventing colon cancer. which information should be included in the presentation? a. wear a high filtration mask when around chemicals b. eat several servings of cruciferous vegetables daily c. take a multiple vitamin daily d. do not engage in high risk sexual beahvior

b The initial nursing action is to assess and treat the self-inflicted injuries. Injuries from lacerated wrist can lead to life-threatening situation.

the police arrive at the ED with a client who has lacerated both wrists. which is the initial nursing action? a. administer an antianxiety agent b. assess and treat the wound sites c. secure and record a detailed history d. encourage and assist the client to ventilate feelings

a a depressed suicidal client often gives away that which is a value as a way of saying goodbye and wanting to be remembered

which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? a. the adolescent gives away a DVD and a cherished autographed picture of a performer b. the adolescent runs out of the therapy group, swearing at the group leader, and to her room c. the adolescent becomes angry while speaking on the telephone and slams down the receiver d. the adolescent gets angry with her roommate when the roommate borrows the clients clothes without asking

a Ineffective coping related to punitive super ego reflects an intra-personal theory of the ideology of OCD. The punitive super ego is a concept contained in freuds psychosocial theory of personality development

which nursing diagnosis reflects the intrapersonal theory of etiology of OCD? a. ineffective coping R/T punitive superego b. ineffective coping R/T active avoidance c. ineffective coping R/T alteration in serotonin d. ineffective coping R/T classic conditioning

a Come to experience suicidal ideation's must be monitored closely to prevent suicide attempts. By monitoring at irregular intervals the nurse would prevent client from recognizing patterns of observation. If a client recognizes a pattern of observation the client can use the time in which he or she is not observed to plan and implement a suicide attempt

which nursing intervention takes priority when working with a newly admitted client experiencing suicidal ideations? a. monitor the client at close but irregular intervals b. encourage the client to participate in group therapy c. enlist friends and family to assist the client in remaining safe after discharge d. remind the client that is takes 6-8 weeks for antidepressants to be fully effective

a, c a sentinel even it something that requires immediate attention and investigation as to why it occurred.

which of the following are examples of a sentinel event? select TWO a. a patient commits suicide in the hospital b. a patient develops nausea after being given a medication c. a surgeon performs wrong site surgery d. a patient loses his balance and scratched his arm while catching himself e. a newborn infant loses 5% of its body weight after birth

d the belief that Abnormalities in various regions of the brain cars OCD is an explanation of OCD ideology from a biological theory perspective

which statement explains the etiology of OCD from a histological theory perspective? a. individuals diagnosed with OCD have weak and underdeveloped egos b. obsessive and compulsive behaviors are a conditioned response to a traumatic event c. regression to the pre-Oedipal anal sadistic phase d. abnormalities in various regions of the brain have been implicated in the cause of OCD