PN NCLEX 6th Edition- Mental Health
The nurse is collecting data on a client who is actively hallucinating. Which nursing statement should be therapeutic at this time?
"Sometimes people hear things or voices others can't hear."
Treatment that involves pairing a stimulus attractive to the client with an unpleasant event is known as which type of therapy?
Aversion therapy
A client who was admitted to the mental health unit 1 month ago with agoraphobia is cooperative, sharing with peers, and makes appropriate suggestions during group discussions. The nurse concludes that this client's behavior is most consistent with:
Improvement
The nurse is assisting in developing a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which?
A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.
A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. The nurse's most important aspect of care is to maintain client safety and do which?
Assign a staff member to the client who will remain with him or her at all times.
The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for this phase?
Assist in making appropriate referrals.
The nursing student is asked to identify the characteristics of bulimia nervosa. Which response by the student indicates a need to further research of the disorder?
Body weight well below ideal range
In planning activities for the depressed client, especially during the early stages of hospitalization, which is best?
Encourage the client to participate in a structured daily program of activities.
A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which?
Escort the manic client to his or her room.
The nurse is monitoring a client with anorexia nervosa. Which statement by the client would indicate to the nurse that treatment has been effective?
"My friends and I went out to lunch today."
A client is scheduled to have electroconvulsive therapy (ECT). Which information would the nurse tell the client?
Amnesia of events occurring near the period of the therapy is common.
A client who is suicidal tells the nurse, "All I want to do is end it all." Which is the appropriate nursing response?
"What do you mean by that?"
The nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why don't you just leave me alone?" The nurse should make which therapeutic response to the client?
"I can see that you are upset. I'll be back in a few minutes to see how you are doing."
The nurse working the evening shift is assisting clients in getting ready to go to sleep. A client diagnosed with obsessive-compulsive disorder (OCD) becomes upset and agitated and asks the nurse to sit down and talk. Which response by the nurse would be best at this time?
"I can see that you're upset. I'm willing to listen."
The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response?
"I cannot discuss any client situation with you."
A psychiatric client diagnosed with schizophrenia approaches the nurses' station and shouts, "Shut up. I told you to be quiet." Looking at the nurse, the client says, "Can't you hear them shouting at me?" Which would be the nurse's best response?
"I don't hear the voices, but I can see how upsetting it must be for you."
A hospitalized client who is experiencing delusions and has a diagnosis of schizophrenia says to the nurse, "I know that the doctor is talking to the CIA to get rid of me." Which should be the nurse's best response?
"I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?"
An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member indicates the client has learned positive coping skills?
"I feel better able to care for my father now that I know where to obtain assistance."
A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is an appropriate response by the nurse?
"I hear what you are saying, but I don't share your belief."
While discharge planning for a female teenager with anorexia nervosa, the nurse suggests that the teenager attends a meeting of the local chapter of anorexia nervosa and associated disorders. Which responses by the teenager indicate that she will likely be compliant with this suggestion? Select all that apply.
"I'm going to do whatever it takes to get better." "I'll go and participate as much as I can in the group discussions."
A client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house, ready to plan our activities for the day." Which is the therapeutic nursing response?
"It must be hard to accept that she has passed away."
The nurse is caring for an older, depressed client whose son was killed in an armed robbery after murdering two people. The client says, "I don't know what I did wrong. His dad died a hero in Vietnam when he was only 2 years old, but he's had everything. When he threw the cat up against the wall to see if it landed on its feet and stole money from me and denied it, his sister covered for him." The nurse plans to make which therapeutic response to the client?
"It seems as if you or your daughter feel regret?"
A 15-year-old client who is pregnant and unwed, says, "My life was unbearable before I met Johnny. My mother beats me up every day and my dad has been sleeping with me since I was 10 years old!" Which response is appropriate for the nurse to make?
"It seems that you needed help to separate from your family. Do you feel you are ready to have a baby with Johnny?"
The nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard here all week and this is my day of rest. I'll get up at 11:30." Which would be the nurse's best response?
"Let me know if you change your mind, and I'll get you something to eat."
A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? Select all that apply.
"My husband always brings me flowers and apologizes after he hits me." boyfriend yells and accuses me of having an affair if I am late after work." "I have bruises all over my body. I am frequently clumsy and fall a lot."
A client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend and states that he "cannot sing." Which response by the nurse is therapeutic?
"Perhaps you could just enjoy the music without singing."
The nurse is caring for a client who says, "I don't want you to touch me. I'll take care of myself!" The nurse should make which therapeutic response to the client?
"Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do everything for yourself as you request."
A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse should make which therapeutic response to the client?
"Tell me about your difficulty sleeping."
While the nurse is providing care, a client angrily reports to the nurse that the health care provider purposefully provided wrong information about her diagnosis and states, "The doctor lied to me." Which nursing response would likely be a barrier to further communication with the client?
"The health care provider would never lie to you."
The nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, "I haven't had an appetite at all for the last few weeks." Which response by the nurse would be therapeutic?
"You haven't had an appetite at all?"
A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client?
"You're feeling angry that your family continues to hope for you to be 'cured'?"
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.
-Communicate expected behaviors to the client. -Assist the client in developing means of setting limits on personal behavior. -Be clear with the client regarding the consequences of exceeding limits set regarding behavior.
The nurse is caring for a client in the acute manic stage of bipolar disorder and plans to use which interventions to assist in maintaining a safe environment? Select all that apply.
-Provide high-calorie finger foods. -Decrease the light and noise level on the unit. -Restrict the client's access to money and other valuables
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate?
A client receiving diagnostic tests
On data collection, which behavior should the nurse expect a client diagnosed with agoraphobia to describe?
A fear of leaving the house
A client has just been admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder (OCD). The nurse observes the client for compulsive behavior that denotes repetition in which?
Actions
The licensed practical nurse is assisting in the admittance of a client who has been involuntarily committed to the behavioral health unit. Which actions by the client before hospitalization led to the commitment? Select all that apply.
Client threatened to commit suicide. Client threatened to kidnap his spouse.
The nurse is monitoring a client with a history of opioid abuse for signs of withdrawal. The nurse monitors this client for which signs and symptoms associated with opioid withdrawal?
Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia
A client who has a gastrostomy tube for feeding refuses to participate in the plan of care, will not make eye contact, and does not speak to the family or visitors. The nurse identifies that this client is using which type of coping mechanism?
Distancing
The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response should be therapeutic?
Do you recall needing to be hospitalized because you stopped your medication?
The police arrive at the emergency room with a client who has seriously lacerated both wrists. The initial nursing action is which?
Examine and treat the wound sites.
Which are appropriate interventions for caring for the client in alcohol withdrawal? Select all that apply
Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically. Provide reality orientation as appropriate.
A client experiencing a severe major depressive episode is unable to address activities of daily living. The appropriate nursing intervention is which?
Feed, bathe, and dress the client as needed until the client can perform these activities independently.
Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?
Get a written prescription from the health care provider (HCP) and obtain an informed consent.
A client with moderate depression who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by taking which action?
Increasing the level of suicide precautions
The nurse is caring for a client with a diagnosis of agoraphobia. Which behaviors exhibited by the client would support this diagnosis?
Makes excuses for not leaving the house
The nurse caring for a client who has been diagnosed with stage 3 Alzheimer's disease and should expect to observe which behaviors in this client? Select all that apply.
Misplacing a valuable object
An emergency department nurse is caring for an older client who may have been physically abused by her son. In planning care for the client, which is the priority nursing action?
Notify the social worker to investigate the situation.
The nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action?
Observing rigid rules and regulations
A client cannot leave the house without checking the stove and the iron many times. The client is often late for appointments and occasionally even misses engagements as a result of this behavior. The nurse interprets that this client's symptoms are compatible with which anxiety disorder?
Obsessive-compulsive disorder
The nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. The nurse determines that obesity for this client most likely represents which?
Protection from the risk of intimacy
The client diagnosed with paranoid schizophrenia has been exceedingly agitated, is threatening and shouting at everyone, and is refusing to participate in therapy. The nurse takes which initial action?
Provide for safety by recognizing the level of client anxiety and setting limits.
The nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines which action is the immediate priority of care?
Provide safety for both the client and other clients on the unit.
A client with depression reports to the nurse that she has not been sleeping or eating adequately. The nurse should plan to do which to assist the client in meeting nutritional needs?
Provide small, frequent meals.
A client in a manic state emerges from her room. She is topless and is making sexual remarks and gestures toward staff and peers. Which is an appropriate nursing action?
Quietly approach the client, escort her to her room, and assist her in getting dressed.
The nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which nursing action is the priority?
Removing the client from any immediate danger
A client is scheduled to have electroconvulsive therapy (ECT). Which problem should the nurse include in the plan as a priority?
Risk for aspiration
The nurse notices a "paranoid stare" during a conversation with the client diagnosed with posttraumatic stress disorder (PTSD). The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be most beneficial?
Share the observation with the client and help the client recognize his or her feelings.
A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathology after a lengthy workup. In planning care for this client, it is important that the nurse understand that the client is suffering from:
Somatization disorder
The nurse is assisting in conducting a group therapy session. During the session a client threatens to act out physically and states that he will punch another member of the group. Which is the appropriate nursing action?
Tell the client that he may talk about his anger but cannot act on it during the group session.
During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. Which interpretation should the nurse make of this behavior?
The client is displaying typical behaviors that can occur during termination
During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. Which interpretation should the nurse make of this behavior?
The client is displaying typical behaviors that can occur during termination.
The nurse is monitoring a client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client?
The client asks to meet with a lawyer to take care of unfinished business.
Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?
The client gives away a DVD and a cherished autographed picture of the performer.
The nurse is collecting data from a client in crisis and is determining the potential for self-harm. Which data would indicate that the client is a very high risk for suicide?
The client has an immediate plan for a suicide attempt.
A client in the mental health unit engages in repeated hand washing throughout the day. The nurse understands that these repetitive behaviors develop for which reason?
The client is unconsciously attempting to control unpleasant thoughts or feelings
A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, the nurse expects which?
The client presents a harm to self.
The nurse is collecting data from a client who has recently been violently raped. Which data indicates that the client is experiencing rape-trauma syndrome?
The client reports nightmares involving being stalked when alone at night.
A hospitalized client who recently experienced the loss of a spouse is grieving. The client progresses well and is approaching discharge. Which is an appropriate outcome for this client?
The client verbalizes stages of grief and plans to attend a community grief group.
The nurse reviews the plan of care for a suicidal client admitted to the hospital. The nurse notes documentation of the client's loss of a spouse, which occurred several years ago. The client progresses well and is approaching discharge. Which is an appropriate goal for this client's care?
The client verbalizes stages of grief and plans to attend a community grief group.
A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse describes the components of this form of therapy to the client and reinforces which client instruction?
The client will be introduced to short periods of exposure to the phobic object while in a relaxed state.
The nurse is working with a victim of rape in a clinic setting and assists in developing a plan of care for the client. Which is an inappropriate short-term initial goal?
The client will resolve feelings of fear and anxiety related to the rape trauma.
A nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse would determine that this type of crisis could be caused by:
The death of a loved one
A client is diagnosed with schizophrenia. The nurse is asked to assist in preparing a nursing care plan for the client. In the planning, the nurse understands that it is important that:
Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition.
A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which?
Use a night light and turn off the television.
A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which?
Weight loss
The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which?
What do you find difficult about this situation?"
The nurse is caring for a client with an eating disorder and knows that which signs/symptoms indicate that the client is dealing with anorexia nervosa? Select all that apply.
Lanugo Amenorrhea
A client has been hospitalized and has participated in substance abuse therapy group sessions. On discharge, the client has consented to participate in Alcoholics Anonymous (AA) community groups. Which statement by the client best indicates to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use?
"I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people."
A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which appropriate response to the client?
"It must be frightening to you. Has something made you feel that your food is poisoned?"
A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse should be therapeutic?
"It's okay to grieve and be angry with your daughter and anyone else for a time."
A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. Which comments by the nurse would be therapeutic at this time?
"What is causing you to become agitated?"
The nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client?
"What is causing you to become agitated?"
Which client is most likely at risk to become a victim of elder abuse?
A 90-year-old woman with advanced Parkinson's disease
A client is attending a Gamblers Anonymous meeting for the first time. The model used by this group is the 12-step program developed by Alcoholics Anonymous. The nurse understands that the first step in the 12-step program is which?
Admitting to having a problem
The wife of a client who abuses alcohol tells the nurse she cannot "do it alone" any longer and asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which community group?
Al-Anon
A client with a diagnosis of a recurrent major depression, exhibiting psychotic features, is admitted to the mental health unit. In an attempt to create a safe environment for the client, the nurse designs a plan of care that deals specifically with which aspect of the client's disorder?
Altered thought processes
A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior?
The client is at increased risk for suicide.
The nurse is caring for a client who has been treated with long-term antipsychotic medication. As part of the nursing care plan, the nurse monitors for tardive dyskinesia. Which should the nurse observe with tardive dyskinesia?
Abnormal movements and involuntary movements of the mouth, tongue, and face
A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care?
Avoid joking or laughing in the presence of the client.
A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse identifies which symptoms or behaviors as requiring immediate intervention?
Constant physical activity and poor oral intake
A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which?
Denial
The nurse is assisting in developing a plan of care for a paranoid client who experiences religious delusions. Which short-term goal would be most appropriate?
Develops a relationship to help reduce the frequency of the delusions
The nurse is assigned to assist in the care of a client with obsessive-compulsive disorder (OCD). The nurse should place first priority on which action when planning care for this client?
Establish a trusting nurse-client relationship.
A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which?
Evidence of the client's altered and distorted body image
The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which observation is indicative of the signs/symptoms associated with withdrawal from opioids?
Fever, yawning, irritability, diaphoresis, and diarrhea
The nurse is preparing a care plan for the client with obsessive-compulsive disorder (OCD). The nurse should focus on which as the primary means to accomplish work with this client?
Goals and objectives
A mental health nurse caring for a client diagnosed with mania selects which activity for this client?
Going for a walk with staff
The licensed practical nurse is assisting the registered nurse in admitting a client with an exacerbation of schizophrenia and knows that which signs/symptoms displayed by the client are considered positive symptoms? Select all that apply.
Hallucinations Anhedonia Delusions Neologisms
A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies the visitor to the client's room and takes which action?
Has the client open the gift with the nurse present
A client tells the nurse that he is feeling out of control. The nurse observes that the client is pacing back and forth. Which approach by the nurse is appropriate to maintain a safe environment?
Move the client to a quiet room and talk about his feelings.
The nurse is reviewing the record of a client who is hospitalized for treatment of a panic disorder. The nurse notes that the client was admitted by voluntary hospitalization. During the day, the client runs down the hallway and demands release from the hospital. The nurse notes that the client is exhibiting signs of anxiety and attempts to assist the client back to the client's hospital room. The next appropriate nursing action at this time is which?
Notify the registered nurse (RN).
An intoxicated client is brought to the emergency department by local police. The client is told that the health care provider (HCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the HCP immediately. The nurse assisting to care for the client should plan for which appropriate nursing intervention?
Offer to take the client to an examination room until he or she can be treated.
The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?
Open-ended questions and silence
The nurse working in a mental health unit hears that a client has been experiencing "flashbacks." The nurse interprets that this client is exhibiting a sign of which condition?
Posttraumatic stress disorder (PTSD)
The nurse is caring for a client with a somatic disorder and knows that which interventions would be most helpful to this client? Select all that apply.
Reinforce the client's problem-solving abilities. Assess "secondary gains" that the somatic illness provides the client
A client is admitted to the psychiatric unit following a serious suicidal attempt by a drug overdose. Which action should the nurse implement?
Remain with the client at all times.
A client with obsessive-compulsive disorder (OCD) who continually cleans the bathroom becomes enraged with the roommate for using the bar of bathing soap for cleaning the bathroom. The client begins to yell and slaps the roommate. Which action should the nurse take first?
Remove both clients to a separate, safe location.
The nurse is assessing a newly admitted client recently diagnosed with depression. Which data best supports that the client is at risk for self-harm?
Reported hopelessness
The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply.
Restating Listening Maintaining neutral responses Providing acknowledgment and feedback
The nurse is assisting in preparing a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to care for the client to improve communication. Which action would be appropriate for the nurse to suggest including in the plan of care?
Reward the client when a desired behavior is performed.
A woman comes into the emergency department following an assault. She presents with hyperventilation, pacing, rapid speech, and headache. The nurse correctly determines that the client is experiencing which level of anxiety?
Severe
The nurse is collecting data from a client recently diagnosed with paranoid schizophrenia. Which information best supports that the client is at risk for harming another individual?
Sibling stating, "I don't feel safe around my brother."
The nurse is caring for a client diagnosed as having a psychomotor retarded depression. Based on this condition, the nurse should expect to note which behavior in the client?
Slowed walking and talking
The nurse is gathering data from a client with a phobia. The client tells the nurse that he consistently avoids attending community functions because he fears that he will be asked to speak publicly to the members. On the basis of this information, the nurse determines that the client is experiencing which problem?
Social phobia
The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse should expect which?
The client will participate in the treatment plan.
A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." In helping the mother prepare for her daughter's discharge, the nurse should suggest which?
The mother should restrict the amount of chocolate and caffeine products in the home.
The nurse is assisting in preparing a plan of care for the client who will be seen in the mental health clinic for the first time. In preparing for the orientation phase of the therapeutic relationship, the nurse suggests addressing which issue?
The parameters of the relationship
An agoraphobic client has been diagnosed with major depression. The nurse notes that the client is not eating adequately and at times refuses to eat. To meet the client's nutritional needs, the nurse plans which action?
To provide small frequent meals
A furiously angry and aggressive client was put in restraints and was told that the restraints would be removed once the client regained control. The nurse appropriately removes the restraints when which action occurs?
When no acts of aggression are observed within 1 hour after release of two extremity restraints
The nurse is assigned to care for a client at risk for alcohol withdrawal. The nurse monitors the client, knowing that the early signs of withdrawal will usually develop within which time after cessation or reduction of alcohol intake?
Within a few hours
A client was admitted to a medical unit because the client suddenly experienced total deafness. The client undergoes numerous tests to determine the cause of the deafness. All test results are negative, and there seems to be no organic reason why this client cannot hear. On further review of the client's record, the nurse notes that the client became deaf after witnessing a murder. Based on this information and the results of the diagnostic tests, which condition should the nurse suspect the client may be experiencing?
A conversion disorder
A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse?
"You understand that people fear for their children, but you're feeling unfairly treated?"
The nurse must choose a roommate for a client who is in a state of starvation due to anorexia nervosa. The nurse should avoid choosing which client as a roommate for the client with anorexia nervosa?
A client with pneumonia
A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right!" Which action should the nurse take?
Identify recent behaviors or accomplishments that demonstrate skill or ability.
The nurse is caring for a client who was recently admitted for anorexia nervosa. Upon entering the client's room, the nurse finds the client in the middle of a series of sets of rapid sit-ups. Which action should the nurse take?
Interrupt the client and offer to take her for a walk.
The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate?
Interrupt the client and offer to take her for a walk.
The nurse prepares the plan of care for a client with late-stage Alzheimer's disease who resides in a long-term care facility. Which would be priority concerns to include? Select all that apply.
Risk for injury Risk for infection Risk for aspiration Impaired verbal communication
A client who attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, should take which action?
Stay with the client at all times.
The nurse is assisting in conducting a group therapy session, and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which?
Suggest that the client stop talking and try listening to others.
An adolescent is returning home after an acute psychiatric hospitalization following a suicide attempt. Which action would be least effective in preparing the client to return to a safe and effective care environment?
Suggest that the mother's boyfriend move out of the home.
The nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse makes which determination?
The client has the right to demand and obtain release from the hospital.
A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on self. The initial data collection should focus on which information?
The physical condition of the client
The nurse is caring for a client who is suspected of being dependent on drugs. Which question should be appropriate for the nurse to ask when collecting data from the client regarding drug abuse?
"How much do you use and what effect does it have on you?"
During a group meeting, a client diagnosed with posttraumatic stress disorder (PTSD) verbalizes difficulty with maintaining realistic behavior. Which response by the nurse would be therapeutic?
"I can see that you are upset about this. Let's talk about this some more."
The nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates the need for further teaching about this self-help group?
"The leader of this self-help group is the nurse or psychiatrist."
The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which would be a therapeutic response by the nurse?
"What aspects of this situation are the most difficult for you?"
The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?
"You must be feeling all alone at this point."
A client with lung cancer says to the nurse, "I'm sick and tired of my family telling me not to worry and that a cure will be discovered before I know it." Which response by the nurse is therapeutic?
"You're feeling angry that your family is hoping for a cure?"
The nurse is caring for a client with depression in the mental health unit who is refusing to take the prescribed oral antidepressant. Which are the nurse's best actions to this client's medication refusal? Select all that apply.
-Notify the health care provider. -Document the refusal of medication. -Ask the client why he is refusing the medication.
The registered nurse has written an outcome statement of "Client will feel less anxious by the end of session" for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply.
-Stay with the client. -Administer anxiolytics medications if prescribed. -Ensure the client is in an environment with little stimuli.
A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that involves which?
Reexperiencing recollections of the trauma
The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which?
Psychomotor retardation and side effects of medication
The nurse is collecting data on a client with the diagnosis of anorexia nervosa. Which findings are indicative of anorexia nervosa? Select all that apply.
A high achiever Personality changes Lanugo over the back and extremities
A woman is admitted to an inpatient psychiatric unit with the diagnosis of anorexia nervosa. A behavior therapy approach is used as part of her treatment plan. Which is the purpose of the behavior therapy approach?
Help the client identify and examine dysfunctional thoughts and beliefs.
A client admitted with depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today the client appears in the dayroom dressed and well groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. The nurse should take which initial action after noting this client's behavior?
Speak to the client personally about the nurse's observations and ask if the client is thinking about suicide.
Which nursing approach is important when administering an antianxiety agent to a client with acute severe anxiety?
Stay with the client until the medication becomes effective.
A client with a history of depression and several suicide attempts is admitted to the mental health unit reporting severe suicidal thoughts. The nurse should focus the initial data collection on which information?
The presence of existing suicidal thoughts
