PASS 3400 FINAL

Which of the following points should the nurse include when teaching a client about panic disorder?

1. Staying in the house will eliminate panic attacks. 2. Medication should be taken when symptoms start. 3. Symptoms of a panic attack are time limited and will abate. 4. Maintaining self-control will decrease symptoms of panic.

A client on the behavioral health unit tells the nurse that she experiences palpitations, trembling, and nausea while traveling alone, outside her home. These symptoms have severely limited her ability to function and have caused her to avoid leaving home whenever possible. The nurse recognizes that this client has symptoms of what disorder?

1. agoraphobia 2. aerophobia 3. thanatophobia 4. hodophobia

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?

A. Risk for injury R/T central nervous system stimulation B. Disturbed thought processes R/T tactile hallucinations C. Ineffective coping R/T powerlessness over alcohol use D. Ineffective denial R/T continued alcohol use despite negative consequences

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediate report to the ED physician?

A. Tactile hallucinations B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention?

A. To assess for emotional strength B. To assess for Wernicke-Korsakoff syndrome C. To assess for tachycardia D. To assess for fine tremors

A client who is pacing and wringing his hands states, "I just need to walk" when questioned by the nurse about what he is feeling. Which of the following responses by the nurse is most therapeutic?

1. "You need to sit down and relax." 2. "Are you feeling anxious?" 3. "Is something bothering you?" 4. "You must be experiencing a problem now."

Which of the following statements describes how elderly clients react to medications?

1. At risk for increased adverse effects 2. Tolerate medication better because they are less active 3. Metabolize medications quickly 4. Need higher doses than younger clients to respond to the same medication

A young child who has been sexually abused has difficulty putting feelings into words. Which of the following should the nurse employ with the child?

1. Engaging in play therapy. 2. Role-playing. 3. Giving the child's drawings to the abuser. 4. Reporting the abuse to a prosecutor.

A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. She tells the nurse that she feels like she's going crazy. Which of the following actions should the nurse use first?

1. Explain the effects of stress on the mind and body. 2. Reassure the client that her feelings are typical reactions to serious trauma. 3. Reassure the client that her symptoms are temporary. 4. Acknowledge the unfairness of the client's situation.

Your client is taking clozapine (Clozaril) and complains of a sore throat. This symptom may be an indication of which adverse reaction?

1. Extrapyramidal reaction 2. Tardive dyskinesia 3. Reye's syndrome 4. Agranulocytosis

Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which of the following conditions?

1. Hyperpyrexia, slow pulse, and weight gain 2. Tachycardia, weight loss, and mood swings 3. Hypotension, weight gain, and listlessness 4. Increased appetite, slowing of sensorium, and arrhythmias

A preadolescent child is suspected of being sexually abused because he demonstrates the self-destructive behaviors of self-mutilation and attempted suicide. Which common behavior should the nurse also expect to assess?

1. Inability to play. 2. Truancy and running away. 3. Head banging. 4. Over-control of anger.

The nurse is caring for a client who has been diagnosed with delirium. Which statement about delirium is true?

1. It's characterized by an acute onset and lasts about 1 month. 2. It's characterized by a slowly evolving onset and lasts about 1 week. 3. It's characterized by a slowly evolving onset and lasts about 1 month. 4. It's characterized by an acute onset and lasts hours to a number of days.

The nurse interviews the family of a client hospitalized with severe depression and suicidal ideation. What family assessment information is essential in formulating an effective care plan? (select all that apply)

1. Physical pain 2. Personal responsibilities 3. Employment skills 4. Communication patterns 5. Role expectations 6. Current family stressors

The nurse is caring for a client with anorexia nervosa who has a nursing diagnosis of Imbalanced nutrition: Less than body requirements related to dysfunctional eating patterns. Which of the following interventions would be supportive for this client? (select all that apply)

1. Provide small, frequent meals. 2. Monitor weight gain. 3. Allow the client to skip meals until the antidepressant levels are therapeutic. 4. Encourage the client to keep a journal. 5. Monitor the client during meals and for 1 hour after meals.

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 diagnosis?

1. Schizophrenia 2. Paranoid personality 3. Bipolar illness 4. Obsessive-compulsive disorder (OCD)

A married female client has been referred to the mental health center because she is depressed. The nurse notices bruises on her upper arms and asks about them. After denying any problems, the client starts to cry and says, "He didn't really mean to hurt me, but I hate for the kids to see this. I'm so worried about them." Which of the following is the most crucial information for the nurse to determine?

1. The type and extent of abuse occurring in the family. 2. The potential of immediate danger to the client and her children. 3. The resources available to the client. 4. Whether the client wants to be separated from her husband.

A client visits the physician's office to seek treatment for depression, feelings of hopelessness, poor appetite, insomnia, fatigue, low self-esteem, poor concentration, and difficulty making decisions. The client states that these symptoms began at least 2 years ago. Based on this report, the nurse suspects:

1. cyclothymic disorder. 2. atypical affective disorder. 3. major depression. 4. dysthymic disorder.

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:

1. dilated pupils and slurred speech. 2. rapid speech and agitation. 3. dilated pupils and agitation. 4. euphoria and constricted pupils.

While shopping at a mall, a woman experiences an episode of extreme terror accompanied by anxiety, tachycardia, trembling, and fear of going crazy. A friend drives her to the emergency department, where a physician rules out physiological causes and refers her to the psychiatric resident on call. To control the client's anxiety, the nurse caring for this client expects the resident to prescribe:

1. haloperidol 2. lorazepam 3. bupropion 4. paroxetine

Which term refers to the primary unconscious defense mechanism that keeps intense, anxiety-producing situations out of a person's conscious awareness?

1. introjection 2. regression 3. repression 4. denial

A client with chronic schizophrenia who takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These findings suggest which life-threatening reaction:

1. tardive dyskinesia. 2. dystonia. 3. neuroleptic malignant syndrome. 4. akathisia.

A 13-year-old client's father has recently been deployed to Afghanistan. Since deployment, the client has begun to participate in isolative behaviors, truancy, vandalism, and fighting. The pediatric nurse practitioner should identify this behavior with which adjustment disorder?

A. An adjustment disorder with anxiety B. An adjustment disorder with disturbance of conduct C. An adjustment disorder with mixed disturbance of emotions and conduct D. An adjustment disorder unspecified

A delusional client approaches the nurse, stating, "I am the Easter bunny," and insisting that the nurse refer to him as such. The belief appears to be fixed and unchanging. Which nursing interventions should the nurse implement when working with this client? (select all that apply)

1. Consistently use the client's name in interaction. 2. Smile at the humor of the situation. 3. Agree that the client is the Easter Bunny. 4. Logically point out why the client couldn't be the Easter Bunny. 5. Provide an as-needed medication. 6. Provide the client with structured activities.