nurse labt

Which of the following is one of the advantages of the newer antipsychotic medication risperidone (Risperdal)?

A lower incidence of extrapyramidal effects

Initial intervention for the client should be to:

Accept her fears without criticizing

Which neurotransmitter has been implicated in the development of Alzheimer's disease?

Acetylcholine

When planning the therapeutic milieu, it is MOST important to select group activities which

Achieve clients' therapeutic goals

A client taking the monoamine oxidase inhibitor (MAOI) antidepressant isocarboxazid (Marplan) is instructed by the nurse to avoid which foods and beverages?

Aged cheese and red wine

Propranolol (Inderal) is used in the mental health setting to manage which of the following conditions?

Antipsychotic-induced akathisia and anxiety

A man with a 5-year history of multiple psychiatric admissions is brought to the emergency department by the police. He was found wandering the streets disheveled, shoeless, and confused. Based on his previous medical records and current behavior, he is diagnosed with chronic undifferentiated schizophrenia. The nurse should assign the highest priority to which nursing diagnosis?

Anxiety Explanation: Option A: For this client, the highest-priority nursing diagnosis is Anxiety (severe to panic-level), manifested by the client's extreme withdrawal and attempt to protect himself from the environment. The nurse must act immediately to reduce anxiety and protect the client and others from possible injury

When working with a male client suffering phobia about black cats, Nurse Trish should anticipate that a problem for this client would be?

Anxiety when discussing phobia

A client is about to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching session, the nurse should provide which instruction to the client?

Apply a sunscreen before being exposed to the sun

Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa would be...

Cardiac dysrhythmias resulting to cardiac arrest

Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that this is typical of?

Confabulation

Freud explains anxiety as:

Conflict between id and superego

A nurse is teaching a stress-management program for client. Which of the following beliefs will the nurse advocate as a method of coping with stressful life events?

Control over one's response to stress is possible

The nurse is teaching a group of clients about the mood-stabilizing medications lithium carbonate. Which medications should she instruct the clients to avoid because of the increased risk of lithium toxicity?`

Diuretics Explanation: The use of diuretics would cause sodium and water excretion, which would increase the risk of lithium toxicity. Clients taking lithium carbonate should be taught to increase their fluid intake and to maintain normal intake of sodium.

A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate (Prolixin Decanoate) by I.M. injection. Three days later, the client has muscle contractions that contort the neck. This client is exhibiting which extrapyramidal reaction?

Dystonia

A 45-year-old woman with a history of depression tells a nurse in her doctor's office that she has difficulty with sexual arousal and is fearful that her husband will have an affair. Which of the following factors would the nurse identify as least significant in contributing to the client's sexual difficulty?

Education and work history Age, health status, physical attributes and relationship issues have great influence on sexual expression.

A 32-year-old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate:

Effective self-boundaries

Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed?

Electroconvulsive therapy Electroconvulsive therapy is an effective treatment for depression that has not responded to medication.

The following statements describe somatoform disorders:

Expression of conflicts through bodily symptoms

A long-term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop:

Feeling of self-worth

A 39-year-old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often:

Feelings of guilt and inadequacy Explanation: Option C: Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior.

A 75-year-old client has dementia of the Alzheimer's type and confabulates. The nurse understands that this client:

Fills in memory gaps with fantasy.

Nurse Tony was caring for a 41-year-old female client. Which behavior by the client indicates adult cognitive development?

Generates new levels of awareness

Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is known as:

Hallucinations Explanation: Option A: Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no basis in reality.

Positive symptoms of schizophrenia include which of the following?

Hallucinations, delusions, and disorganized thinking

A 20-year-old client was diagnosed with dependent personality disorder. Which behavior is not most likely to be evidence of ineffective individual coping?

Inability to make choices and decision without advise Explanation: Option D: Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them.

A client is admitted to the psychiatric unit with a diagnosis of alcohol intoxication and suspected alcohol dependence. Other assessment findings include an enlarged liver, jaundice, lethargy, and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what is the first priority?

Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output

A client tells the nurse that he is having suicidal thoughts every day. In conferring with the treatment team, the nurse should make which of the following recommendations?

Intensive inpatient treatment

Malingering is different from somatoform disorder because the former:

It is a deliberate effort to handle upsetting events Explanation: Malingering is a conscious simulation of an illness while somatoform disorder occurs unconscious.

An unemployed woman, age 24, seeks help because she feels depressed and abandoned and doesn't know what to do with her life. She says she has quit her last five jobs because her coworkers didn't like her and didn't train her adequately. Last week, her boyfriend broke up with her after she drove his car into a tree after an argument. The client's initial diagnosis is borderline personality disorder. Which nursing observations support this diagnosis?

Lack of self-esteem, strong dependency needs, and impulsive behavior

Nurse Mary is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important?

Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal Question 12 Explanation: Allowing the client to select her own food from the menu will help her feel some sense of control. She must then eat 100% of what she selected. Remaining with the client for at least 1 hour after eating will prevent purging. Bulimic clients should only be allowed to eat food provided by the dietary department.

A 23-year-old client has been admitted with a diagnosis of schizophrenia says to the nurse "Yes, its march, March is little woman". That's literal you know". These statements illustrate:

Loosening of association

Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis, and hyperactivity. Blood pressure is 190/87 mmHg and pulse is 92 bpm. Which of the medications would the nurse expect to administer?

Lorazepam (Ativan)

The nurse is aware that antipsychotic medications may cause which of the following adverse effects?

Lower seizure threshold

Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to:

Manipulate the environment to bring about positive changes in behavior

Nurse Trish is working in a mental health facility; the nurse's priority nursing intervention for a newly admitted client with bulimia nervosa would be...

Monitor client continuously Explanation: Option D: These clients often hide food or force vomiting; therefore they must be carefully monitored.

Nurse Jannah is monitoring a male client who has been placed in restraints because of violent behavior. Nurse determines that it will be safe to remove the restraints when:

No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints.

A client who's actively hallucinating is brought to the hospital by friends. They say that the client used either lysergic acid diethylamide (LSD) or angel dust (phencyclidine [PCP]) at a concert. Which of the following common assessment findings indicates that the client may have ingested PCP?

Nystagmus

Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to the restroom, Nurse Monet should...

Observe her Explanation: Option D: The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurse should watch for clues, such as communicating suicidal thoughts, and messages; hoarding medications and talking about death.

To establish an open and trusting relationship with a female client who has been hospitalized with severe anxiety, the nurse in charge should?

Respect client's need for personal space

A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should carefully observe the client for...

Respiratory difficulties Explanation: Option A: Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles.

Hormonal effects of the antipsychotic medications include which of the following?

Retrograde ejaculation and gynecomastia

The nurse develops a countertransference reaction. This is evidenced by:

Revealing personal information to the client Explanation: Countertransference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts

A client tells a nurse. "Everyone would be better off if I wasn't alive." Which nursing diagnosis would be made based on this statement?

Risk for self-directed violence

A client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority?

The client will work with the nurse to remain safe.

Which factors are most essential for the nurse to assess when providing crisis intervention foe a client?

The client's perception of the triggering event and availability of situational supports Explanation: The most important factors to determine in this situations are the client's perception of the crisis event and the availability of support (including family and friends) to provide basic needs.

Which factor is least important in the decision regarding whether a victim of family violence can safely remain in the home?

The family's socioeconomic status

The nurse is interacting with a family consisting of a mother, a father, and a hospitalized adolescent who has a diagnosis of alcohol abuse. The nurse analyzes the situation and agrees with the adolescent's view about family rules. Which intervention is most appropriate?

The nurse should remain objective and encourage mutual negotiation of issues.

A nurse is evaluating therapy with the family of a client with anorexia nervosa. Which of the following would indicate that the therapy was successful?

The parents reinforce increased decision making by the client. Explanation: One of the core issues concerning the family of a client with anorexia is control. The family's acceptance of the client's ability to make independent decisions is key to successful family intervention. Although the remaining options may occur during the process of therapy they would not necessarily indicate a successful outcome; the central family issues of dependence and independence are not addressed in these responses.

Kellan, a high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome?

The student accepts a referral to a substance abuse counselor

The nurse is teaching a psychiatric client about her prescribed drugs, chlorpromazine and benztropine. Why is benztropine administered?

To reduce extrapyramidal symptoms

A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner?

Using open-ended question and silence

Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of heroin withdrawal?

Vomiting and Diarrhea Explanation: Option D: Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle spasm, fever, nausea, repetitive, abdominal cramps, and backache.

The client with anorexia nervosa is improving if:

Weight gain Explanation: Weight gain is the best indication of the client's improvement. The goal is for the client to gain 1-2 pounds per week.

The nurse is assessing a 17-year-old female who is admitted to the eating disorders unit with a history of weight fluctuation, abdominal pain, teeth erosion, receding gums, and bad breath. She states that her health has been a problem but there are no other concerns in her life. Which of the following assessments will be the least useful as the nurse develops the care plan?

Whether she has a sexual relationship with a boyfriend

Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to alleviate Linda's anxiety. The most therapeutic question by the nurse would be?

Would you like me to talk with you?

Which of the following drugs should Nurse Mary prepare to administer to a client with a toxic acetaminophen (Tylenol) level?

acetylcysteine (Mucomyst)

An elderly man is admitted to the hospital. He was alert and oriented during the admission interview. However, his family states that he becomes disruptive and disoriented around dinnertime. One night he was shouting furiously and didn't know where he was. He was sedated and the next morning he was fine. At dinnertime the disruptive behavior returned. The client is diagnosed as having sundown syndrome. The client's son asks the nurse what causes sundown syndrome. The nurse's best response is that it is attributed to

changes in the sensory environment.

A female client who's at high risk for suicide needs close supervision. To best ensure the client's safety, Nurse Mary should:

check the client frequently at irregular intervals throughout the night

A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is Nurse Alice most likely to administer to reduce the symptoms of alcohol withdrawal?

chlordiazepoxide (Librium) Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal.

The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates such as morphine include:

euphoria and constricted pupils.

A client with paranoid schizophrenia is admitted to the psychiatric unit of a hospital. Nursing assessment should include careful observation of the client's:

thinking, perceiving, and decision-making skills

A male client has approached the nurse asking for advice on how to deal with his alcohol addiction. Nurse Sally should tell the client that the only effective treatment for alcoholism is:

total abstinence Explanation: Total abstinence is the only effective treatment for alcoholism.

The nurse is aware that the outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder?

Accept responsibility for own behaviors

A client with obsessive-compulsive disorder is hospitalized on an inpatient unit. Which nursing response is most therapeutic?

Accepting the client's obsessive-compulsive behaviors Explanation: A client with obsessive-compulsive behavior uses this behavior to decrease anxiety. Accepting this behavior as the client's attempt to feel secure is therapeutic. When a specific treatment plan is developed, other nursing responses may also be acceptable.

The nurse evaluates the treatment of Mrs. Montez with somatoform disorder as successful if:

Mrs. Montez verbalizes anxiety directly rather than displacing it.

In clients with a cognitive impairment disorder, the phenomenon of increased confusion in the early evening hours is called:

Sundowning

The nurse considers a client's response to crisis intervention successful if the client:

Returns to his previous level of functioning. Explanation: Crisis intervention is based on the idea that a crisis is a disturbance in homeostasis (steady state). The goal is to help the client return to a previous level of equilibrium in functioning.

A client with bipolar disorder, manic type, exhibits extreme excitement, delusional thinking, and command hallucinations. Which of the following is the priority nursing diagnosis?

Risk for other-directed violence Question 14 Explanation: A client with these symptoms would have poor impulse control and would therefore be prone to acting-out behavior that may be harmful to either himself or others

When teaching the family of a client with schizophrenia, the nurse should provide which information?

Support is available to help family members meet their own needs.

Which of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist?

Supportive confrontation Explanation: Option B: The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self.

The nurse is caring for a client with schizophrenia. Which of the following outcomes is the least desirable?

The client spends more time by himself

Which is the desired outcome in conducting desensitization:

The client will be able to overcome his disabling fear Explanation: The client will overcome his disabling fear by gradual exposure to the feared object

A nurse is working with a client who has schizophrenia, paranoid type. Which of the following outcomes related to the client's delusional perceptions would the nurse establish?

The client will demonstrate realistic interpretation of daily events in the unit. Explanation: A client with schizophrenia, paranoid type, has distorted perceptions and views people, institutions, and aspects of the environment as plotting against him. The desired outcome for someone with delusional perceptions would be to have a realistic interpretation of daily events

A nurse is working with a client who has schizophrenia, paranoid type. Which of the following outcomes related to the client's delusional perceptions would the nurse establish?

The client will demonstrate realistic interpretation of daily events in the unit. Explanation: A client with schizophrenia, paranoid type, has distorted perceptions and views people, institutions, and aspects of the environment as plotting against him. The desired outcome for someone with delusional perceptions would be to have a realistic interpretation of daily events.

For a female client with anorexia nervosa, Nurse Jimmy is aware that which goal takes the highest priority?

The client will establish adequate daily nutritional intake

A client was admitted to the psychiatric unit for severe depression. After several days, the client continues to withdraw from other clients. Which of the following would be the MOST appropriate statement by the nurse to promote interaction with other clients?

"Come play Chinese Checkers with Gerry and me."

A client with paranoid personality disorder is admitted to a psychiatric facility. Which remark by the nurse would best establish rapport and encourage the client to confide in the nurse?

"I get upset once in a while, too."

A 15-year-old girl with anorexia has been admitted to a mental health unit. She refuses to eat. Which of the following statements is the best response from the nurse?

"I hope you'll eat your food by mouth. Tube feedings and I.V. lines can be uncomfortable

A 14-year-old client is brought to the clinic by her mother. Her mother expresses concern about her daughter's weight loss and constant dieting. Nurse Kris conducts a health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa?

"I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls."

A 14-year-old client is brought to the clinic by her mother. Her mother expresses concern about her daughter's weight loss and constant dieting. Nurse Kris conducts a health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa?

"I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." Explanation: Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down to a "desirable weight" is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor self-esteem. Most clients with anorexia nervosa don't like the way they look, and their self-perception may be distorted.

A male client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse Linda, which statement by the client most strongly supports a diagnosis of psychoactive substance abuse?

"I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me."

During postprandial monitoring, a female client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response?

"I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."

What would be the best response to the client's repeated complaints of pain:

"I know the feeling is real tests revealed negative results.

Nurse Tina is caring for a client with delirium and states that "look at the spiders on the wall". What should the nurse respond to the client?

"I know you are frightened, but I do not see spiders on the wall" Explanation: Option D: When hallucination is present, the nurse should reinforce reality with the client.

The nurse observes a client pacing in the hall. Which statement by the nurse may help the client recognize his anxiety?

"I notice that you're pacing. How are you feeling?" Question 3 Explanation: By acknowledging the observed behavior and asking the client to express his feelings the nurse can best assist the client to become aware of his anxiety.

A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills in the client's drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be

"Tell me about your week prior to being admitted." Explanation: This is an open-ended question which is non-judgemental and allows for further discussion. The topic is also nonthreatening yet will give the nurse insight into the client"s view of events leading up to admission. It is the only option that is client centered

A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from nurse Julia?

"Tell me how you feel about the accident."

During a private conversation, a client with borderline personality disorder asks the nurse to keep his secret and then displays multiple, self-inflicted, superficial lacerations on the forearms. What is the nurse's best response?

"The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."

She tearfully tells the nurse "I can't take it when she accuses me of stealing her things." Which response by the nurse will be most therapeutic?

"This must be difficult for you and your mother." Explanation: This reflecting the feeling of the daughter that shows empathy.

A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be most helpful in dealing with the client's anger?

"You had to wait. Can we talk about how this is making you feel right now?"

Which of these statements by the nurse reflects the best use of therapeutic interaction techniques?

"You look upset. Would you like to talk about it?"

A client with a history of substance abuse has been attending Alcoholics Anonymous meetings regularly in the psychiatric unit. One afternoon, the client tells the nurse, "I'm not going to those meetings anymore. I'm not like the rest of those people. I'm not a drunk. "What is the most appropriate response?

"You seem upset about the meetings."

A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response?

"You told me you got fired from your last job for missing too many days after taking drugs all night."

A client with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be most appropriate?

"Your behavior won't be tolerated. Go to your room immediately." Option A: The nurse should set limits on client behavior to ensure a comfortable environment for all clients.

She says to the nurse who offers her breakfast, "Oh no, I will wait for my husband. We will eat together" The therapeutic response by the nurse is:

"Your husband is dead. Let me serve you your breakfast."

Since admission 4 days ago, a client has refused to take a shower, stating, "There are poison crystals hidden in the shower head. They'll kill me if I take a shower." Which nursing action is most appropriate?

Accepting these fears and allowing the client to take a sponge bath

A male client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor's dog on fire. When evaluating this client for the potential for violence, nurse Perry should assess for which behavioral clues?

A rigid posture, restlessness, and glaring

Mental health is defined as:

A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively.

The nurse is working with a client who abuses alcohol. Which of the following facts should the nurse communicate to the client?

Abstinence is the basis for successful treatment

A client with panic disorder experiences an acute attack while the nurse is completing an admission assessment. List the following interventions according to their level of priority. a. Remain with the client. b. Encourage physical activity. c. Encourage low, deep breathing. d. Reduce external stimuli. e. Teach coping measures.

ADCBE

David is preoccupied with numerous bodily complaints even after a careful diagnostic workup reveals no physiologic problems. Which nursing intervention would be therapeutic for him?

Acknowledge that the complaints are real to the client, and refocus the client on other concerns and problems.

Nurse Alice is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products?

Aftershave lotion

A male client is being treated for alcoholism. After a family meeting, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. Nurse Lily should suggest that the family join which organization?

Al-Anon Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism.

A male client is being treated for alcoholism. After a family meeting, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. Nurse Lily should suggest that the family join which organization?

Al-Anon Explanation: Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism.

A client with a diagnosis of paranoid schizophrenia comments to the nurse, "How do I know what is really in those pills?" Which of the following is the best response?

Allow him to open the individual wrappers of the medication

A male client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. How should Nurse Anuktakanuk approach her initially?

Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her

What is the best intervention to teach the client when she feels the need to starve?

Approach the nurse and talk out her feelings xplanation: The client with anorexia nervosa uses starvation as a way of managing anxiety. Talking out feelings with the nurse is an adaptive coping

The nurse can BEST ensure the safety of a demented client who wanders from the room by

Attaching a wander-guard sensor band to the client's wrist

Which of the following should be included in the health teachings among clients receiving Valium:

Avoid taking CNS depressant like alcohol. Explanation: Valium is a CNS depressant. Taking it with other CNS depressants like alcohol; potentiates its effect.

A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example of which behavior?

Avolition

A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be:

Badly stained teeth

The nurse would expect a client with early Alzheimer's disease to have problems with:

Balancing a checkbook

A woman is admitted to the psychiatric emergency department. Her significant other reports that she has difficulty sleeping, has poor judgment, and is incoherent at times. The client's speech is rapid and loose. She reports being a special messenger from the Messiah. She has a history of depressed mood for which she has been taking an antidepressant. The nurse suspects which diagno

Bipolar illness Explanation: Option C: Bipolar illness is characterized by mood swings from profound depression to elation and euphoria. Delusions of grandeur along with pressured speech are common symptoms of mania.

Which of the following would best indicate to the nurse that a depressed client is improving?

Changes in vegetative signs

When planning care for a client who has ingested phencyclidine (PCP), nurse Wayne is aware that the following is the highest priority?

Client's safety needs

The nurse correctly teaches a client taking the benzodiazepine oxazepam (Serax) to avoid excessive intake of:

Coffee Explanation: Coffee contains caffeine, which has a stimulating effect on the central nervous system that will counteract the effect of the antianxiety medication oxazepam.

A male client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. Nurse Ryan notes a rise in the client's arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use?

Coronary artery spasm Explanation: Cocaine use may cause such cardiac complications as coronary artery spasm, myocardial infarction, dilated cardiomyopathy, acute heart failure, endocarditis, and sudden death.

A male client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. Nurse Ryan notes a rise in the client's arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use?

Coronary artery spasm Explanation: Cocaine use may cause such cardiac complications as coronary artery spasm, myocardial infarction, dilated cardiomyopathy, acute heart failure, endocarditis, and sudden death. Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of these neurotransmitters at postsynaptic receptor sites. Consequently, the drug is more likely to cause tachyarrhythmias

During which phase of alcoholism is loss of control and physiologic dependence evident?

Crucial phase

Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, "Do you know why people find you repulsive?" this statement most likely would elicit which of the following client reaction?

Defensiveness Explanation: Option A: When the staff member ask the client if he wonders why others find him repulsive, the client is likely to feel defensive because the question is belittling. The natural tendency is to counterattack the threat to self image.

A man is admitted to the nursing care unit with a diagnosis of cirrhosis. He has a long history of alcohol dependence. During the late evening following his admission, he becomes increasingly disoriented and agitated. Which of the following would the client be least likely to experience?

Delusions of grandeu

A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but he can control his use if he chooses. Which coping mechanism is he using?

Denial

In group therapy, a client who has used I.V. heroin every day for the past 14 years says, "I don't have a drug problem. I can quit whenever I want. I've done it before." Which defense mechanism is the client using?

Denial

A 60-year-old female client who lives alone tells the nurse at the community health center "I really don't need anyone to talk to". The TV is my best friend. The nurse recognizes that the client is using the defense mechanism known as?

Denial Explanation: Option D: The client statement is an example of the use of denial, a defense that blocks problem by unconscious refusing to admit they exist.

The nurse understands that electroconvulsive therapy is primary used in psychiatric care for the treatment of:

Depression Explanation: Electroconvulsive therapy (ECT) can provide relief for patients with severe depression who have not been able to feel better with other treatments. In some severe cases where rapid response is necessary or medications cannot be used safely, ECT can even be a first-line intervention. ECT consists of a series of sessions, typically three times a week, for two to four wee

Nurse Penny is aware that the following medical conditions is commonly found in clients with bulimia nervosa?

Diabetes mellitus Explanation: Bulimia nervosa can lead to many complications, including diabetes, heart disease, and hypertension.

A client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition?

Diaphoresis, tremors, and nervousness

A male adult client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition?

Diaphoresis, tremors, and nervousness Explanation: Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability.

A client taking the MAOI phenelzine (Nardil) tells the nurse that he routinely takes all of the medications listed below. Which medication would cause the nurse to express concern and therefore initiate further teaching?

Diphenhydramine (Benadryl) Explanation: Over-the-counter medications used for allergies and cold symptoms are contraindicated because they will increase the sympathomimetic effects of MAOIs, possibly causing a hypertensive crisis.

Conney with borderline personality disorder who is to be discharged soon threatens to "do something" to herself if discharged. Which of the following actions by the nurse would be most important?

Discuss the meaning of the client's statement with her Explanation: Option B: Any suicidal statement must be assessed by the nurse. The nurse should discuss the client's statement with her to determine its meaning in terms of suicide.

In the management of bulimic patients, the following nursing interventions will promote a therapeutic relationship EXCEPT: A.Establish an atmosphere of trust B.Discuss their eating behavior. C.Help patients identify feelings associated with binge-purge behavior D. Teach patient about bulimia nervosa

Discuss their eating behavior. Explanation: The client is often ashamed of her eating behavior.

A 16-year-old girl has returned home following hospitalization for treatment of anorexia nervosa. The parents tell the family nurse performing a home visit that their child has always done everything to please them and they cannot understand her current stubbornness about eating. The nurse analyzes the family situation and determines it is characteristic of which relationship style?

Enmeshment Explanation: Enmeshment is a fusion or over involvement among family members whereby the expectation exists that all members think and act alike. The child who always acts to please her parents is an example of how enmeshment affects development in many cases, a child who develops anorexia nervosa exerts control only in the area of eating behavior.

The emergency department nurse is assigned to provide care for a victim of a sexual assault. When following legal and agency guidelines, which intervention is most important?

Ensure an unbroken chain of evidence. Question 18 Explanation: Establishing an unbroken chain of evidence is essential in order to ensure that the prosecution of the perpetrator can occur. The nurse will also need to preserve the client's privacy and identify the extent of injury. However, it is essential that the nurse follow legal and agency guidelines for preserving evidence. Identifying the assailant is the job of law enforcement, not the nurse.

The nurse formulates a nursing diagnosis of Impaired verbal communication for a client with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention is most appropriate?

Establishing a one-on-one relationship with the client

Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the client is holding his head to one side and complaining of neck and jaw spasms. What should the nurse do?

Evaluate the client for adverse reactions to haloperidol

Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia are?

Excessive weight loss, amenorrhea & abdominal distension

The parents of a young man with schizophrenia express feelings of responsibility and guilt for their son's problems. How can the nurse best educate the family?

Explain the biological nature of schizophrenia Explanation: The parents are feeling responsible and this inappropriate self-blame can be limited by supplying them with the facts about the biologic basis of schizophrenia.

A 45-year-old woman with a history of depression tells a nurse in her doctor's office that she has difficulty with sexual arousal and is fearful that her husband will have an affair. Which of the following factors would the nurse identify as least significant in contributing to the client's sexual difficulty?

Explanation: Education and work history would have the least significance in relation to the client's sexual problem. Age, health status, physical attributes and relationship issues have great influence on sexual expression.

Nurse Mary is assigned to care for a suicidal client. Initially, which is the nurse's highest care priority?

Exploring the nurse's own feelings about suicide

Which of the following is important when restraining a violent client?

Have an organized, efficient team approach after the decision is made to restrain the client.

Nurse Bella is aware that assessment finding is most consistent with early alcohol withdrawal?

Heart rate of 120 to 140 beats/minutes

Which nursing intervention is most appropriate for a client with anorexia nervosa during initial hospitalization on a behavioral therapy unit?

Help establish a plan using privileges and restrictions based on compliance with refeeding. Explanation: Inpatient treatment of a client with anorexia usually focuses initially on establishing a plan for refeeding to combat the effects of self-induced starvation. Refeeding is accomplished through behavioral therapy, which uses a system of rewards and reinforcements to assist in establishing weight restoration. Emphasizing nutrition and teaching the client about the long-term physical consequences of anorexia maybe appropriate at a later time in the treatment program. The nurse needs to assess the client's mealtime behavior continually to evaluate treatment effectiveness.

The nurse provides a referral to Alcoholics Anonymous to a client who describes a 20-year history of alcohol abuse. The primary function of this group is to:

Help members maintain sobriety. Explanation: The primary purpose of Alcoholics Anonymous is to help members achieve and maintain sobriety

Which nursing action is best when trying to diffuse a client's impending violent behavior?

Helping the client identify and express feelings of anxiety and anger

To further assess a client's suicidal potential. Nurse Katrina should be especially alert to the client expression of:

Helplessness & hopelessness

When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the ritual:

Helps the client control the anxiety

The nurse understands that if a client continues to be dependent on heroin throughout her pregnancy, her baby will be at high risk for:

Heroin dependence. Explanation: Babies born to heroin-dependent women are also heroin-dependent and need to go through withdrawal. There is no evidence to support any of the remaining answer choices.

A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is:

Highly famous and important Explanation: Option B: Delusion of grandeur is a false belief that one is highly famous and important.

Charina, a college student who frequently visited the health center during the past year with multiple vague complaints of GI symptoms before course examinations. Although physical causes have been eliminated, the student continues to express her belief that she has a serious illness. These symptoms are typically of which of the following disorders?

Hypochondriasis

Which statement by the client during the initial assessment in the the emergency department is most indicative for suspected domestic violence?

I have tried leaving, but have always gone back."

Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is?

Identify anxiety causing situations Explanation: Option B: Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.

A client with schizophrenia is receiving antipsychotic medication. Which nursing diagnosis may be appropriate for this client?

Ineffective protection related to blood dyscrasias Explanation: Option A: Antipsychotic medications may cause neutropenia and granulocytopenia, life-threatening blood dyscrasias, that warrant a nursing diagnosis of Ineffective protection related to blood dyscrasias. These medications also have anticholinergic effects, such as urine retention, dry mouth, and constipation.

A severely dehydrated teenager admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. Her history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the last month. She is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority?

Initiating caloric and nutritional therapy as ordered

Two nurses are co-leading group therapy for seven clients in the psychiatric unit. The leaders observe that the group members are anxious and look to the leaders for answers. Which phase of development is this group in?

Initiation phase

A client diagnosed with schizoaffective disorder is suffering from schizophrenia with elements of which of the following disorders?

Mood disorder

Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the:

Name of the ingested medication & the amount ingested

A client is admitted with needle tracts on his arm, stuporous and with pin point pupil will likely be managed with:

Narcan (Naloxone) Explanation: Narcan is a narcotic antagonist used to manage the CNS depression due to overdose with heroin

Nurse Amy is aware that the client is at highest risk for suicide?

One who plans a violent death and has the means readily available Explanation: The client at highest risk for suicide is one who plans a violent death (for example, by gunshot, jumping off a bridge, or hanging), has a specific plan (for example, after the spouse leaves for work), and has the means readily available (for example, a rifle hidden in the garage)

Clonidine (Catapres) can be used to treat conditions other than hypertension. Nurse Sally is aware that the following conditions might the drug be administered?

Opiate Withdrawal EXPLANATION: Clonidine (Catapres) can be used to treat conditions other than hypertension. Nurse Sally is aware that the following conditions might the drug be administered?

The nurse enters the room of a client with a cognitive impairment disorder and asks what day of the week it is: what the date, month, and year are; and where the client is. The nurse is attempting to assess:

Orientation

A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation?

Paranoid thoughts Explanation: Option A: Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts.

A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in control of eating habits. The goal for this problem i

Patient will learn problem solving skills

An 11-year-old child diagnosed with conduct disorder is admitted to the psychiatric unit for treatment. Which of the following behaviors would the nurse assess?

Physical aggressiveness, low stress tolerance disregard for the rights of others

A 24-year old client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and feelings?

Provide objective data and feedback regarding the client's weight and attractiveness By focusing on reality, this strategy may help the client develop a more realistic body image and gain self-esteem.

A client begins to experience alcoholic hallucinosis. What is the best nursing intervention at this time?

Providing a quiet environment and administering medication as needed and prescribed

A female client begins to experience alcoholic hallucinosis. Nurse Joy is aware that the best nursing intervention at this time?

Providing a quiet environment and administering medication as needed and prescribed Explanation: Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing oversedation.

A nursing care plan for a male client with bipolar I disorder should include:

Providing a structured environment

Mr. Peterson, 35, is admitted for bipolar illness, manic phase, after assaulting his landlord in an argument over Mr. Peterson is staying up all night playing loud music. Mr. Peterson is hyperactive, intrusive, and has rapid, pressured speech. He has not slept in three days and appears thin and disheveled. Which of the following is the most essential nursing action at this time?

Providing for client safety by limiting his privileges Explanation: Food and fluids are necessary. However, Mr. Peterson's hyperactivity does not allow him to sit quietly to eat. Finger foods "on the run" will provide needed nourishment.

Nurse Helen is assigned to care for a client with anorexia nervosa. Initially, which nursing intervention is most appropriate for this client?

Providing one-on-one supervision during meals and for 1 hour afterward Explanation: Because the client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 hour afterward

The nurse explains to a mental health care technician that a client's obsessive-compulsive behaviors are related to unconscious conflict between id impulses and the superego (or conscience). On which of the following theories does the nurse base this statement?

Psychoanalytic theory Explanation: Psychoanalytic is based on Freud's beliefs regarding the importance of unconscious motivation for behavior and the role of the id and superego in opposition to each other.

The nurse explains to a mental health care technician that a client's obsessive-compulsive behaviors are related to unconscious conflict between id impulses and the superego (or conscience). On which of the following theories does the nurse base this statement?

Psychoanalytic theory Question 2 Explanation: Psychoanalytic is based on Freud's beliefs regarding the importance of unconscious motivation for behavior and the role of the id and superego in opposition to each other.

An agitated and incoherent client, age 29, comes to the emergency department with complaints of visual and auditory hallucinations. The history reveals that the client was hospitalized for paranoid schizophrenia from ages 20 to 21. The physician prescribes haloperidol (Haldol), 5 mg I.M. The nurse understands that this drug is used for this client to treat:

Psychosis

Which method would a nurse use to determine a client's potential risk for suicide?

Question the client directly about suicidal thoughts

Which method would a nurse use to determine a client's potential risk for suicide?

Question the client directly about suicidal thoughts Explanation: Directly questioning a client about suicide is important to determine suicide risk. The client may not bring up this subject for several reasons, including guilt regarding suicide, wishing not to be discovered, and his lack of trust in staff.

A client who abuses alcohol and cocaine tells a nurse that he only uses substances because of his stressful marriage and difficult job. Which defense mechanisms is this client using?

Rationalization Explanation: Rationalization is the defense mechanism that involves offering excuses for maladaptive behavior. The client is defending his substance abuse by providing reasons related to life stressors. This is a common defense mechanism used by clients with substance abuse problems.

Nurse Penny is aware that the symptoms that distinguish post-traumatic stress disorder from other anxiety disorder would be:

Re-experiencing the trauma in dreams or flashback

Which nursing intervention is most appropriate for a client with Alzheimer's disease who has frequent episodes emotional lability?

Reduce environmental stimuli to redirect the client's attention. Explanation: The client with Alzheimer's disease can have frequent episode of labile mood, which can best be handled by decreasing a stimulating environment and redirecting the client's attention.

Mike is admitted to a psychiatric unit with a diagnosis of undifferentiated schizophrenia. Which of the following defense mechanisms is probably used by Mike?

Regression

Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal?

Regular Coffee Explanation: Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. Serving coffee top the client may add to tremors or wakefulness.

Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)?

Report a sore throat or fever to the physician immediately

The nurse is administering a psychotropic drug to an elderly client who has history of benign prostatic hypertrophy. It is most important for the nurse to teach this client to:

Report incomplete bladder emptying Urinary retention is a common anticholinergic side effect of psychotic medications, and the client with benign prostatic hypertrophy would have increased risk for this problem.

A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on this finding, the nurse Lenny should formulate a nursing diagnosis of:

Risk for violence: Self-directed related to impulsive mutilating acts

A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on this finding, the nurse Lenny should formulate a nursing diagnosis of:

Risk for violence: Self-directed related to impulsive mutilating acts Explanation: The predominant behavioral characteristic of the client with borderline personality disorder is impulsiveness, especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn't substantiate the other options.

Nurse Monette is aware that extremely depressed clients seem to do best in settings where they have:

Routine Activities Explanation: Option B: Depression usually is both emotional & physical. A simple daily routine is the best, least stressful and least anxiety producing.

The nurse is caring for a severely depressed client who has just been admitted to the in-client psychiatric unit. Which of the following is a PRIORITY of care?

Safety

Nurse Harry is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?

Set up a strict eating plan for the client Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals — not given privacy. Exercise must be limited and supervised.

Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan?

Set-up a strict eating plan for the client Explanation: Option B: Establishing a consistent eating plan and monitoring client's weight are important to this disorder.

Mario is complaining to other clients about not being allowed by staff to keep food in his room. Which of the following interventions would be most appropriate?

Setting limits on the behavior Explanation: The nurse needs to set limits on the client's manipulative behavior to help the client control dysfunctional behavior. A consistent approach by the staff is necessary to decrease manipulation.

Which of the following will the nurse use when communicating with a client who has a cognitive impairment?

Short words and simple sentences

A client with paranoid thoughts refuses to eat because he believes the food is poisoned. The MOST appropriate initial action is to

Simply state the food is not poisoned

Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the client's room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should...

Sit beside the client in silence and occasionally ask open-ended question

A 30-year-old male employee frequently complains of low back pain that leads to frequent absences from work. Consultation and tests reveal negative results. The client has which somatoform disorder?

Somatoform Pain Disorder

A client is experiencing anxiety attack. The most appropriate nursing intervention should include?

Staying with the client and speaking in short sentences

Which of the following signs should the nurse expect in a client with known amphetamine overdose?

Tachycardia Explanation: Option B: Amphetamines are central nervous system stimulants. They cause sympathetic stimulation, including hypertension, tachycardia, vasoconstriction, and hyperthermia.

Prior to administering chlorpromazine (Thorazine) to an agitated client, the nurse should:

Take the client's blood pressure Explanation: Because chlorpromazine (Thorazine) can cause a significant hypotensive effect (and possible client injury), the nurse must assess the client's blood pressure (lying, sitting, and standing) before administering this drug.

A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom?

Tardive dyskinesia

Primary level of prevention is exemplified by:

Teaching the client stress management techniques Explanation: Primary level of prevention refers to the promotion of mental health and prevention of mental illness. T

A female client with anorexia nervosa describes herself as "a whale." However, the nurse's assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should nurse Angel be included in the plan of care?

Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy Explanation: A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health

A female client with anorexia nervosa describes herself as "a whale." However, the nurse's assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should nurse Angel be included in the plan of care?

Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy Explanation: A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health. Instead of protecting the client's health, options A, B, and C may serve to make the client defensive and more entrenched in her unrealistic body image.

A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused?

The child doesn't cry when the shoulder is examined

Which client outcome is most appropriately achieved in a community approach setting in psychiatric nursing?

The client demonstrates self-reliance and social adaptation Explanation: A therapeutic community is designed to help individuals assume responsibility for themselves, to learn how to respect and communicate with others, and to interact in a positive manner.

When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation?

The client identifies anxiety-producing situations

A client with a bipolar disorder exhibits manic behavior. The nursing diagnosis is Disturbed thought processes related to difficulty concentrating, secondary to flight of ideas. Which of the following outcome criteria would indicate improvement in the client?

The client speaks in coherent sentences. Question 10 Explanation: A client exhibiting flight of ideas typically has a continuous speech flow and jumps from one topic to another. Speaking in coherent sentences is an indicator that the client's concentration has improved and his thoughts are no longer racing.

The nurse is working with a client with a somatoform disorder. Which client outcome goal would the nurse most likely establish in this situation?

The client will express anxiety verbally rather than through physical symptoms. Explanation: The client with a somatoform disorder displaces anxiety onto physical symptoms. The ability to express anxiety verbally indicates a positive change toward improved health. The remaining responses do not indicate any positive change toward increased coping with anxiety.

Which of the following outcome criteria is appropriate for the client with dementia?

The client will follow an establishing schedule for activities of daily living.

A 25 -year old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority?

The client will work with the nurse to remain safe EXPLANATION: The priority goal in alcohol withdrawal is maintaining the client's safety. Committing to a drug-free lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensuring the client's safety is the nurse's top priority.

A 25 -year old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority?

The client will work with the nurse to remain safe Explanation: The priority goal in alcohol withdrawal is maintaining the client's safety. Committing to a drug-free lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensuring the client's safety is the nurse's top priority.

A 20 year old college student is admitted to the medical ward because of sudden onset of paralysis of both legs. Extensive examination revealed no physical basis for the complaint. The nurse plans intervention based on which correct statement about conversion disorder?

The conversion symptom has symbolic meaning to the client.

Which information is most essential in the initial teaching session for the family of a young adult recently diagnosed with schizophrenia?

The distressing symptoms of this disorder can respond to treatment with medications. Question 12 Explanation: This statement provides accurate information and an element of hope for the family of a schizophrenic client. Although the remaining statements are true, they do not provide the empathic response the family needs after just learning about the diagnosis. These facts can become part of the ongoing teaching.

For a female client with anorexia nervosa, nurse Rose plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa?

They tend to overprotect their children

Marco approached Nurse Trisha asking for advice on how to deal with his alcohol addiction. Nurse Trisha should tell the client that the only effective treatment for alcoholism is:

Total abstinence

Important teaching for clients receiving antipsychotic medication such as haloperidol (Haldol) includes which of the following instructions?

Use sunscreen because of photosensitivity. Take the antipsychotic medication with food

Which nursing intervention is best for facilitating communication with a psychiatric client who speaks a foreign language?

Use the services of an interpreter

An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function. The daughter revealed that the client used her toothbrush to comb her hair. She is manifesting:

agnosia Explanation: This is the inability to recognize objects.

Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. Nurse Melinda should suspect:

alcohol withdrawl

A client receiving fluphenazine decanoate (Prolixin Decanoate) therapy develops pseudoparkinsonism. The physician is likely to prescribe which drug to control this extrapyramidal effect?

amantadine (Symmetrel) Explanation: Option B: An antiparkinsonian agent, such as amantadine, may be used to control pseudoparkinsonism;

A client is admitted to the emergency department after being found unconscious. Her blood pressure is 82/50 mm Hg. She is 5′ 4″ (1.6 m) tall, weighs 79 lb (35.8 kg), and appears dehydrated and emaciated. After regaining consciousness, she reports that she has had trouble eating lately and can't remember what she ate in the last 24 hours. She also states that she has had amenorrhea for the past year. She is convinced she is fat and refuses food. The nurse suspects that she has:

anorexia nervosa.

Kevin is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with:

antisocial

On discharge after treatment for alcoholism, a client plans to take disulfiram (Antabuse) as prescribed. When teaching the client about this drug, the nurse emphasizes the need to:

avoid all products containing alcohol

A male client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, nurse Lorena should expect early withdrawal symptoms to:

begin anytime within the next 1 to 2 days Explanation: Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later.

A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to:

begin anytime within the next 1 to 2 days.

A client with schizophrenia who receives fluphenazine (Prolixin) develops pseudoparkinsonism and akinesia. What drug would the nurse administer to minimize extrapyramidal symptoms?

benztropine (Cogentin) Benztropine is an anticholinergic drug administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. It works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS).

Another client is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum.

cocaine

A 35 year old male has intense fear of riding an elevator. He claims " As if I will die inside." This has affected his studies The client is suffering from:

claustrophobia

A 34-year-old woman is admitted for treatment of depression. Which of these symptoms would the nurse be least likely to find in the initial assessment?

increased interest in sex

The client admitted for alcohol detoxification develops increased tremors, irritability, hypertension and fever. The nurse should be alert for impending:

delirium tremens Explanation: Delirium Tremens is the most extreme central nervous system irritability due to withdrawal from alcohol

The nurse is planning care for a client who has a phobic disorder manifested by a fear of elevators. Which goal would need to be accomplished first? The client

demonstrates the relaxation response when asked. Explanation: The ability to use relaxation is basic to treatment of phobia. Clients with phobias are resistant to insight therapy.

When a husband takes out his work frustrations and anger by abusing his wife at home, the nurse would identify this crisis as which type?

dispositional crisis Explanation: A dispositional crisis is a response to an external situational crisis. External anger at work is the dispositional crisis displaced to his wife through abuse.

A client is admitted to the psychiatric unit with active psychosis. The physician diagnoses schizophrenia after ruling out several other conditions. Schizophrenia is characterized by:

disturbances in affect, perception, and thought content and form.

A 17-year-old gymnast is admitted to the hospital due to weight loss and dehydration secondary to starvation. Which of the following nursing diagnoses will be given priority for the client?

fluid volume deficit Explanation: Fluid volume deficit is the priority over altered nutrition

A client whose husband just left her has a recurrence of anorexia nervosa. Nurse Vic caring for her realizes that this exacerbation of anorexia nervosa results from the client's effort to:

gain control of one part of her life Explanation: By refusing to eat, a client with anorexia nervosa is unconsciously attempting to gain control over the only part of her life she feels she can control.

A student nurse is caring for a 75-year-old client who is very confused. The student's communication tools should include:

gentle touch while guiding ADLs (activities of daily living)

The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:

hallucinations

Nurse Fey is aware that the drug of choice for treating Tourette syndrome?

haloperidol (Haldol) Explanation: Haloperidol is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil are antidepressants and aren't used to treat Tourette syndrome

Macoy and Helen seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. When intervening with this couple, nurse Gerry knows they are at risk for repeated violence because the husband:

has learned violence as an acceptable behavior

The characteristic manifestation that will differentiate bulimia nervosa from anorexia nervosa is that bulimic individuals

have episodic binge eating and purging Explanation: Bulimia is characterized by binge eating which is characterized by taking in a large amount of food over a short period of time.

A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is:

highly important or famous

During a group therapy session in the psychiatric unit, a client constantly interrupts with impulsive behavior and exaggerated stories that cast her as a hero or princess. She also manipulates the group with attention-seeking behaviors, such as sexual comments and angry outbursts. The nurse realizes that these behaviors are typical of:

histrionic personality disorder.

Nurse Tamara is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:

identify anxiety-causing situations

Dementia unlike delirium is characterized by:

insidious onset Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. A,C and D (slurred speech, clouding, sensory perception change) are all characteristics of delirium.

A client is admitted to the inpatient adolescent unit after being arrested for attempting to sell cocaine to an undercover police officer. The nurse plans to write a behavioral contract. To best promote compliance, the contract should be written:

jointly by the client and nurse.

Nurse Anna can minimize agitation in a disturbed client by:

limiting unnecessary interaction

A client with schizophrenia tells the nurse he hears the voices of his dead parents. To help the client ignore the voices, the nurse should recommend that he:

listen to a personal stereo through headphones and sing along with the music.

Which non-antipsychotic medication is used to treat some clients with schizoaffective disorder?

lithium carbonate (Lithane)

A male client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, Dr. Smith is most likely to prescribe which drug?

lorazepam (Ativan) Explanation: The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Clozapine and thiothixene are antipsychotic agents, and lithium carbonate is an antimanic agent; these drugs aren't used to manage alcohol withdrawal syndrome.

The nurse is providing care for a client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:

methadone

A female client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, nurse Tair should plan to:

monitor vital signs, serum electrolyte levels, and acid-base balance Explanation: An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level, and acid base balance is crucial

A female client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, nurse Tair should plan to:

monitor vital signs, serum electrolyte levels, and acid-base balance Explanation: An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level, and acid base balance is crucial.

When monitoring a client recently admitted for treatment of cocaine addiction, the nurse notes sudden increases in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe:

nifedipine and esmolol

When monitoring a female client recently admitted for treatment of cocaine addiction, nurse Aaron notes sudden increases in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe:

nifedipine and esmolol

A male client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal chest pain. The electrocardiogram (ECG) shows a 1-mm ST-segment elevation the anteroseptal leads and T-wave inversion in leads V3 to V5. Considering the client's history of drug abuse, nurse Greg expects the physician to prescribe:

nitroglycerin (Nitro-Bid IV

Important teaching for a client receiving risperidone (Risperdal) would include advising the client to:

notify the physician if the client notices an increase in bruising

The nurse is discussing electroconvulsive therapy (ECT) with a client who asks how long it will be before she feels better. The nurse explains that the beneficial effects of ECT usually occur within

one week

The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client:

remains in a safe and secure environment

Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam (Serax). Before administering the medication, nurse Gina should be prepared for which common adverse effect?

seizures

How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client's delusional thoughts and hallucinations eliminated?

several weeks

A male client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. Nurse Gian realizes that these symptoms probably result from:

thiamine deficiency Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake.

The nurse assigned in the detoxification unit attends to various patients with substance-related disorders. A 45 years old male revealed that he experienced a marked increase in his intake of alcohol to achieve the desired effect This indicates:

tolerance Explanation: tolerance refers to the increase in the amount of the substance to achieve the same effects. A. Withdrawal refers to the physical signs and symptoms that occur when the addictive substance is reduced or withheld. B. Intoxication refers to the behavioral changes that occur upon recent ingestion of a substance. D. Psychological dependence refers to the intake of the substance to prevent the onset of withdrawal symptoms.

A 16-year-old boy is admitted to the facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include:

violence on television.

A client is admitted to the psychiatric hospital with a diagnosis of catatonic schizophrenia. During the physical examination, the client's arm remains outstretched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm. This client is exhibiting:

waxy flexibility.