Psych Final 4-5 Questions

A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin Decanoate) from a home health nurse. The client refuses medication at one regularly scheduled home visit. Which nursing intervention is ethically appropriate? A. Allow the client to decline the medication and document. B. Tell the client that if the medication is refused, hospitalization will occur. C. Arrange with a relative to add medication to the client's morning orange juice. D. Call for help to hold the client down while the injection is administered.

ANS: A It is ethically and legally appropriate for the nurse to allow the client to decline the medication and provide accurate documentation. The client's right to refuse treatment should be upheld unless the refusal puts the client or others in harm's way. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

An inpatient client, whom the treatment team has determined to be a danger to self, gives notice of intention to leave the hospital. What information should the nurse recognize as having an impact on the treatment team's next action? A. State law determines how long a psychiatric facility can hold a client. B. Federal law determines if the client is competent. C. The client's family involvement will determine if discharge is possible. D. Hospital policies will determine treatment team actions.

ANS: A Most states commonly cite that in an emergency a client who is dangerous to self or others may be involuntarily hospitalized. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment

A client who is admitted to the inpatient psychiatric unit and is taking Thorazine presents to the nurse with severe muscle rigidity, tachycardia, and a temperature of 105F (40.5C). The nurse identifies these symptoms as which of the following conditions? A. Neuroleptic malignant syndrome B. Tardive dyskinesia C. Acute dystonia D. Agranulocytosis

ANS: A Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

Arthur, who is diagnosed with obsessive-compulsive disorder, reports to the nurse that he can't stop thinking about all the potentially life threatening germs in the environment. What is the most accurate way for the nurse to document this symptom? A. Patient is expressing an obsession with germs. B. Patient is manifesting compulsive thinking. C. Patient is expressing delusional thinking about germs. D. Patient is manifesting arachnophobia of germs.

ANS: A Obsessions are unwanted, intrusive, repetitive thoughts. Compulsions are unwanted, repetitive behavior patterns in response to obsessive thoughts that are efforts to reduce anxiety. KEY: Cognitive Level: Analysis | Integrated Processes: Communication and Documentation | Client Need: Psychosocial Integrity

A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions? A. "I will need scheduled bloodwork in order to monitor for toxic levels of this drug." B. "I won't stop taking this medication abruptly, because there could be serious complications." C. "I will not drink alcohol while taking this medication." D. "I won't take extra doses of this drug because I can become addicted."

ANS: A The client indicates a need for additional information about taking benzodiazepines when stating the need for blood work to monitor for toxic levels. No blood work is needed when taking a short-acting benzodiazepine. The client should understand that taking extra doses of a benzodiazepine may result in addiction and that the drug should not be taken in conjunction with alcohol. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurse's coworker observes this action but does nothing for fear of repercussion. What is the ethical interpretation of the coworker's lack of involvement? A. Taking no action is still considered an action by the coworker. B. Taking no action releases the coworker from ethical responsibility. C. Taking no action is advised when potential adverse consequences are foreseen. D. Taking no action is acceptable, because the coworker is only a bystander.

ANS: A The coworker's lack of involvement can be interpreted as an action taken. The coworker is experiencing an ethical dilemma in which a decision needs to be made between two unfavorable alternatives. Although the coworker may be struggling with ethical decision making, he or she has witnessed another nurse dispensing medication outside of the scope of practice; therefore, from a legal perspective, this should be reported. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations? A. Refusing to give any information to the caller, citing rules of confidentiality B. Refusing to give any information to the caller by hanging up C. Affirming that the person has been seen at the facility but providing no further information D. Suggesting that the caller speak to the client's therapist

ANS: A The most appropriate action by the nurse is to refuse to give any information to the caller. Admission to the facility would be considered protected health information (PHI) and should not be disclosed by the nurse without prior client consent. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A client diagnosed with panic disorder states, "When an attack happens, I feel like I am going to die." Which is the most appropriate nursing reply? A. "I know it's frightening, but try to remind yourself that this will only last a short time." B. "Death from a panic attack happens so infrequently that there is no need to worry." C. "Most people who experience panic attacks have feelings of impending doom." D. "Tell me why you think you are going to die every time you have a panic attack."

ANS: A The most appropriate nursing reply to the client's concerns is to empathize with the client and provide encouragement that panic attacks last only a short period. Panic attacks usually last minutes but can, rarely, last hours. Symptoms of depression are also common with this disorder. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A woman returns home after delivering a stillborn infant to find that neighbors have dismantled the nursery that she and her husband planned. According to Worden, how should a nurse expect the neighbor's action to affect the woman's grieving task completion? A. This action may hamper the woman from accepting the reality of the loss. B. This action would help the woman forget the sorrow and move on with life. C. This action communicates full support from her neighbors. D. This action would motivate the woman to look to the future and not the past.

ANS: A The nurse should anticipate that this action could hinder the woman from accepting the reality of the loss. The first task in Worden's grief process is to accept the reality of the loss. It is common for individuals to refuse to believe that the loss has occurred. Behaviors may include misidentifying an individual in the environment as their loved one, retaining possessions of the lost loved one, and removing all reminders of the loved one so as not to have to face reality. The bereaved person is considered an active participant in the grief process and the above-mentioned behaviors are part of that process. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A client has a history of excessive fear of water. What is the term that a nurse should use to describe this specific phobia, and under what subtype is this phobia identified? A. Aquaphobia, a natural environment type of phobia B. Aquaphobia, a situational type of phobia C. Acrophobia, a natural environment type of phobia D. Acrophobia, a situational type of phobia

ANS: A The nurse should determine that an excessive fear of water is identified as aquaphobia, which is a natural environment type of phobia. Natural environment-type phobias are fears about objects or situations that occur in the natural environment, such as a fear of heights or storms. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing reply? A. "Your child has a chemical imbalance of the brain, which leads to altered thoughts." B. "Your child's hallucinations are caused by medication interactions." C. "Your child has too little serotonin in the brain, causing delusions and hallucinations." D. "Your child's abnormal hormonal changes have precipitated auditory hallucinations."

ANS: A The nurse should explain that a chemical imbalance of the brain leads to altered thought processes. Hallucinations, or false sensory perceptions, may occur in all five senses. The client who hears voices is experiencing an auditory hallucination. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance

After threatening to jump off a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first? A. "Are you currently thinking about harming yourself?" B. "Why do you want to harm yourself?" C. "Have you thought about the consequences of your actions?" D. "Who is your emergency contact person?"

ANS: A The nurse should first assess the client for current suicidal thoughts to minimize risk of harm and provide appropriate interventions. A suicidal client is experiencing a psychiatric emergency. The crisis team should prioritize safety by assessing the client for thoughts of self-harm. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client requests information on several medications in order to make an informed choice about management of depression. A nurse should provide this information to facilitate which ethical principle? A. Autonomy B. Beneficence C. Nonmaleficence D. Justice

ANS: A The nurse should provide the information to support the client's autonomy. A client who is capable of making independent choices should be permitted to do so. In instances when clients are incapable of making informed decisions, a legal guardian or representative would be asked to give consent. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

Which statement should indicate to a nurse that an individual is experiencing a delusion? A. "There's an alien growing in my liver." B. "I see my dead husband everywhere I go." C. "The IRS may audit my taxes." D. "I'm not going to eat my food. It smells like brimstone."

ANS: A The nurse should recognize that a client who claims that an alien is inside his or her body is experiencing a delusion. Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

What term should a nurse use when describing a response to grieving that includes a sudden physical collapse and paralysis, and which cultural group would be associated with this behavior? A. "Falling out" in the African American culture B. "Body rocking" in the Vietnamese American culture C. "Conversion disorder" in the Jewish American culture D. "Spirit possession" in the Native American culture

ANS: A The nurse should use the term "falling out" to describe a sudden physical collapse and paralysis. This behavior is associated with the African American culture. The individuals may also experience an inability to see or speak yet maintain hearing and understanding. KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nursing instructor is teaching about the typical grieving behaviors of Chinese Americans. Which student statement would indicate that more instruction is needed? A. "In this culture, the color red is associated with death and is considered bad luck." B. "In this culture, there is an innate fear of death." C. "In this culture, emotions are not expressed openly." D. "In this culture, death and bereavement are centered on ancestor worship."

ANS: A The nursing instructor should evaluate that more instruction is needed if a student states that the color red is associated with death and bad luck. Chinese Americans consider the color white as associated with death and both the colors black and white are considered bad luck. Red is the ultimate color of luck in this culture. Chinese Americans also avoid purchasing insurance because of the fear that they may be inviting death. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred? A. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder." B. "Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder." C. "Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks." D. "Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks."

ANS: A The student indicates learning has occurred when he or she states that clonazepam is a particularly effective treatment for panic disorder. Clonazepam is a type of benzodiazepine that can be abused and lead to physical dependence and tolerance. It can be used on an as-needed basis to reduce anxiety and its related symptoms. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client begins to smash furniture, cannot be "talked down," and refuses medications. Which is the most appropriate nursing intervention? A. Call a violence code. B. Ask the ward clerk to put in a call for the physician. C. Place the client in seclusion. D. Place the client in four-point restraints.

ANS: A In this situation the nurse must have adequate, trained help to prevent injury to the client or staff. Calling a violence code will access this help. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

Which client statement demonstrates improvement in anger/aggression management? A. "I realize I have a problem expressing my anger appropriately." B. "I know I can't use physical force anymore, but I can intimidate someone with my words." C. "It's bad to feel as angry as I feel. I'm working on eliminating this poisonous emotion entirely." D. "Because my wife seems to be the one to set me off, I've decided to remain separated from her."

ANS: A The client is recognizing and taking responsibility for personal anger. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? Select all that apply. A. "Tell me what happened." B. "What coping methods have you used, and did they work?" C. "Describe to me what your life was like before this happened." D. "Let's focus on the current problem." E. "I'll assist you in selecting functional coping strategies."

ANS: A, B, C In the assessment phase, the nurse should gather information regarding the precipitating stressor and the resulting crisis. Focusing on the current problem and selecting functional coping strategies are nursing interventions rather than assessments. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Which of the following are effective interventions that a nurse should utilize when caring for an inpatient client who expresses anger inappropriately? Select all that apply. A. Maintain a calm demeanor. B. Clearly delineate the consequences of the behavior. C. Use therapeutic touch to convey empathy. D. Set limits on the behavior. E. Teach the client to avoid "I" statements related to expression of feelings.

ANS: A, B, D The nurse should determine that when working with an inpatient client who expresses anger inappropriately, it is important to maintain a calm demeanor, clearly define the consequences, and set limits on the behavior. The use of therapeutic touch may not be appropriate and could escalate the client's anger. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A nurse is leading a bereavement group. Which of the following group members should the nurse identify as being at high risk for having difficulty grieving? Select all that apply. A. A widower who has recently experienced the death of two good friends B. A man whose wife died suddenly after a cerebrovascular accident C. A widow who, after a year, allowed removal of life support from her terminally ill husband D. A woman who had a competitive relationship with her recently deceased brother E. A young couple whose child recently died of a genetic disorder

ANS: A, B, D, E Several factors have been identified that may make the grief response more difficult: grieving when the bereaved person was strongly dependent on the lost entity, the relationship with the lost entity was highly ambivalent, the individual experienced a number of recent losses, the loss is that of a young person, the individual's physical or psychological health is unstable, and the bereaved person perceived responsibility for the loss. A widow who has experienced the process of loss for an extended period of time is more likely in the stage of acceptance and resolution of grief. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

An instructor is teaching nursing students about Worden's grief process. According to Worden, which of the following client behaviors would delay or prolong the grieving process? Select all that apply. A. Refusing to allow self to think painful thoughts B. Indulging in the pain of loss C. Using alcohol and drugs D. Idealizing the object of loss E. Recognizing that time will heal

ANS: A, C, D The nurse should identify that refusing to allow self to think painful thoughts, using alcohol and drugs, and idealizing the object of loss will delay or prolong the grieving process. Task II of Worden's grief process is working through the pain or grief. Pain must be acknowledged and resolved in order to move on. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

Which of the following types of care should the interdisciplinary team of hospice provide? Select all that apply. A. Physical care available on a 24/7 basis B. Counseling on the addictive properties of pain-management medications C. Discussions related to death and dying D. Explorations of new, aggressive treatments E. Assistance with obtaining spiritual support and guidance

ANS: A, C, E The nurse should identify that the interdisciplinary team of hospice provides physical care available on a 24/7 basis, discussions related to death and dying, and assistance with obtaining spiritual support and guidance. Hospice is a program that provides palliative and supportive care to meet the needs of people who are dying. Support is also provided to client families. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Which is an example of an intentional tort? A. A nurse fails to assess a client's obvious symptoms of neuroleptic malignant syndrome. B. A nurse physically places an irritating client in four-point restraints. C. A nurse makes a medication error and does not report the incident. D. A nurse gives patient information to an unauthorized person.

ANS: B A tort is a violation of civil law in which an individual has been wronged and can be intentional or unintentional. A nurse who physically places an irritating client in restraints has touched the client without consent and has committed an intentional tort. Examples of unintentional torts are malpractice and negligence actions. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment

A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization? A. The client will refrain from ritualistic behaviors during daylight hours. B. The client will wake early enough to complete rituals prior to breakfast. C. The client will participate in three unit activities by day 3. D. The client will substitute a productive activity for rituals by day 1.

ANS: B An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to breakfast. The nurse should also provide a structured schedule of activities and later in treatment begin to gradually limit the time allowed for rituals. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

A despondent client, who has recently lost her husband of 30 years, tearfully states, "I'll feel a lot better if I sell my house and move away." Which nursing reply is most appropriate? A. "I'm confident you know what's best for you." B. "This may not be the best time for you to make such an important decision." C. "Your children will be terribly disappointed." D. "Tell me why you want to make this change."

ANS: B During crisis intervention, the nurse should guide the client through a problem-solving process. The nurse should help the individual confront the source of the problem, encourage the individual to discuss changes he or she would like to make, and encourage exploration of feelings about aspects of the crisis that cannot be changed. The nurse should also assist the client in determining whether any changes are realistic and if timing of change is appropriate. This response encourages the client to think through what may be an impulsive decision. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Which is the most accurate description of the nursing diagnosis of spiritual distress? A. The client reports no church affiliations. B. The client struggles to identify meaning and purpose in life. C. The client reports seeing the spirit of his deceased wife. D. The client reports that meditation helps him feel connected spiritually.

ANS: B One common nursing diagnosis in relation to complicated grief (and some authors would argue that all grief is complicated) is the risk for spiritual distress, which addresses the person's sense of meaning, purpose, and outlook for the future. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

During a hiring interview, which response by a nursing applicant should indicate that the applicant operates from an ethical egoism framework? A. "I would want to be treated in a caring manner if I were mentally ill." B. "This job will pay the bills, and the workload is light enough for me." C. "I will be happy caring for the mentally ill. Working in Med/Surg kills my back." D. "It is my duty in life to be a psychiatric nurse. It is the right thing to do."

ANS: B The applicant's comment reflects an ethical egoism framework. This framework promotes the idea that decisions are based on what is good for the individual and may not take the needs of others into account. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment

1. In response to a student's question regarding choosing a psychiatric specialty, a charge nurse states, "Mentally ill clients need special care. If I were in that position, I'd want a caring nurse also." From which ethical framework is the charge nurse operating? A. Kantianism B. Christian ethics C. Ethical egoism D. Utilitarianism

ANS: B The charge nurse is operating from a Christian ethics framework. A basic principle in Christian ethics is to "do unto others as you would have them do unto you." Kantianism states that decisions should be based on moral law and that actions are bound by a sense of moral duty. Utilitarianism holds that decisions should be made with a focus on the end result being happiness. Ethical egoism promotes the idea that what is right is good for the individual. KEY: Cognitive Level: Analysis | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment

A nursing student questions an instructor regarding the order for fluvoxamine (Luvox), 300 mg daily, for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor reply is most accurate? A. "High doses of tricyclic medications will be required for effective treatment of OCD." B. "Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD." C. "The dose of Luvox is low due to the side effect of daytime drowsiness and nighttime insomnia." D. "The dosage of Luvox is outside the therapeutic range and needs to be questioned."

ANS: B The most accurate instructor response is that SSRI doses in excess of what is effective for treating depression may be required in the treatment of OCD. SSRIs have been approved by the U.S. Food and Drug Administration for the treatment of OCD. Common side effects include headache, sleep disturbances, and restlessness. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A family member is seeking advice about an elderly parent who seems to worry unnecessarily about everything. The family member states, "Should I seek psychiatric help for my mother?" Which is an appropriate nursing reply? A. "My mother also worries unnecessarily. I think it is part of the aging process." B. "Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning." C. "From what you have told me, you should get her to a psychiatrist as soon as possible." D. "Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications."

ANS: B The most appropriate reply by the nurse is to explain to the family member that anxiety is considered abnormal when it is out of proportion and impairs functioning. Anxiety is a normal reaction to a realistic danger or threat to biological integrity or self-concept. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia? A. Establishing personal contact with family members. B. Being reliable, honest, and consistent during interactions. C. Sharing limited personal information. D. Sitting close to the client to establish rapport.

ANS: B The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the client's needs and maintain a calm attitude when dealing with agitated behavior. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Which situation exemplifies both assault and battery? A. The nurse becomes angry, calls the client offensive names, and withholds treatment. B. The nurse threatens to "tie down" the client and then does so against the client's wishes. C. The nurse hides the client's clothes and medicates the client to prevent elopement. D. The nurse restrains the client without just cause and communicates this to family.

ANS: B The nurse in this situation has committed both the acts of assault and battery. Assault refers to an action that results in fear and apprehension that the person will be touched without consent. Battery is the touching of another person without consent. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

During an admission assessment, a nurse asks a client diagnosed with schizophrenia, "Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption? A. Delusions of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur

ANS: B The nurse is assessing the client for delusions of influence when asking if the client has ever felt that objects or persons have control of the client's behavior. Delusions of control or influence are manifested when the client believes that his or her behavior is being influenced. An example would be if a client believes that a hearing aid receives transmissions that control personal thoughts and behaviors. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nurse is caring for an Irish client who has recently lost a spouse. The client states to the nurse, "I'm planning an elaborate wake and funeral." According to George Engel, what purpose would these rituals serve? A. To delay the recovery process initiated by the loss of the client's spouse B. To facilitate the acceptance of the loss of the client's spouse C. To avoid dealing with grief associated with the loss of the client's spouse D. To eliminate emotional pain related to the loss of the client's spouse

ANS: B The nurse should anticipate that the purpose of these rituals is to facilitate the acceptance of the loss of the client's spouse. Resolution of the loss is the fourth stage in Engel's grief process, in which the bereaved experiences a preoccupation with the loss, which gradually decreases over time. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

An inpatient client with a known history of violence suddenly begins to pace. Which client behavior should alert a nurse to escalating anger and aggression? A. The client requests prn medications. B. The client has a tense facial expression and body language. C. The client refuses to eat lunch. D. The client sits in group therapy with back to peers.

ANS: B The nurse should assess that tense facial expressions and body language may indicate that a client's anger is escalating. The nurse should conduct a thorough assessment of the client's past and current violent behaviors and develop interventions for de-escalation. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

. A client is diagnosed with terminal cancer. Which situation would the nurse assess as reflecting Kübler-Ross's grief stage of "anger"? A. The client registers for an iron-man marathon to be held in 9 months. B. The client is a devoted Catholic but refuses to attend church and states that his faith has failed him. C. The client promises God to give up smoking if allowed to live long enough to witness a grandchild's birth. D. The client gathers family in order to plan a funeral and make last wishes known.

ANS: B The nurse should assess that the client is in the "anger" stage of grieving when the client refuses to attend church and states that his faith has failed him. Anger is the second stage of Kübler-Ross's grief process, in which the reality of the situation is realized and the individual has feelings of sadness, guilt, shame, helplessness, and hopelessness. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client diagnosed with schizophrenia tells a nurse, "The 'Shopatouliens' took my shoes out of my room last night." Which is an appropriate charting entry to describe this client's statement? A. "The client is experiencing command hallucinations." B. "The client is expressing a neologism." C. "The client is experiencing a paranoia." D. "The client is verbalizing a word salad."

ANS: B The nurse should describe the client's statement as experiencing a neologism. A neologism is when a client invents a new word that is meaningless to others but may have symbolic meaning to the client. Word salad refers to a group of words that are put together randomly. KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Psychosocial Integrity

A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, "I can't function any longer under all this stress." Which type of crisis is the client experiencing? A. Maturational/developmental crisis B. Psychiatric emergency crisis C. Anticipated life transition crisis D. Traumatic stress crisis

ANS: B The nurse should determine that the client is experiencing a psychiatric emergency crisis. Psychiatric emergencies occur when crisis situations result in severe impairment, incompetence, or inability to assume personal responsibility. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |Client Need: Psychosocial Integrity

A client refuses to go on a cruise to the Bahamas with his spouse because of fearing that the cruise ship will sink and all will drown. Using a cognitive theory perspective, the nurse should use which of these statements to explain to the spouse the etiology of this fear? A. "Your spouse may be unable to resolve internal conflicts, which result in projected anxiety." B. "Your spouse may be experiencing a distorted and unrealistic appraisal of the situation." C. "Your spouse may have a genetic predisposition to overreacting to potential danger." D. "Your spouse may have high levels of brain chemicals that may distort thinking."

ANS: B The nurse should explain that from a cognitive perspective the client is experiencing a distorted and unrealistic appraisal of the situation. From a cognitive perspective, fear is described as the result of faulty cognitions. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Which grieving behaviors should a nurse anticipate when caring for a Southwest Navajo Indian client? A. Celebrating the life of a deceased person with festivities and revelry B. Not expressing grief openly and reluctance to touch a dead body C. Holding a prayerful vigil for a week following the person's death D. Expressing grief openly and publicly and erecting an altar in the home to honor the dead

ANS: B The nurse should identify that a Navajo client would not express grief openly and would be reluctant to touch a dead body. Navajo Indians do not bury the body of a deceased person for 4 days after death, and they conduct a cleaning ceremony prior to burial. The dead are buried with their shoes on the wrong feet and rings on their index fingers. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Which client should a nurse identify as a potential candidate for involuntarily commitment? A. A client living under a bridge in a cardboard box B. A client threatening to commit suicide C. A client who never bathes and wears a wool hat in the summer D. A client who eats waste out of a garbage can

ANS: B The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatments is a danger to self and requires emergency treatment. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety? A. Assess for medication noncompliance B. Note escalating behaviors and intervene immediately C. Interpret attempts at communication D. Assess triggers for bizarre, inappropriate behaviors

ANS: B The nurse should note escalating behaviors and intervene immediately to maintain this client's safety. Early intervention may prevent an aggressive response and keep the client and others safe. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care

A nurse is caring for a client who is experiencing a flat affect, paranoia, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? A. Paranoia, anhedonia, and anergia are positive symptoms of schizophrenia. B. Paranoia, neologisms, and echolalia are positive symptoms of schizophrenia. C. Paranoia, anergia, and echolalia are negative symptoms of schizophrenia. D. Paranoia, flat affect, and anhedonia are negative symptoms of schizophrenia.

ANS: B The nurse should recognize that positive symptoms of schizophrenia include paranoid delusions, neologisms, and echolalia. The negative symptoms of schizophrenia include flat affect, anhedonia, and anergia. Positive symptoms reflect an excess or distortion of normal functions. Negative symptoms reflect a decrease or loss of normal functions. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nursing instructor is teaching about specific phobias. Which student statement should indicate that learning has occurred? A. "These clients do not recognize that their fear is excessive, and they rarely seek treatment." B. "These clients have overwhelming symptoms of panic when exposed to the phobic stimulus." C. "These clients experience symptoms that mirror a cerebrovascular accident (CVA)." D. "These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis."

ANS: B The nursing instructor should evaluate that learning has occurred when the student knows that clients experiencing phobias have a panic level of fear that is overwhelming and unreasonable. Phobia is fear cued by a specific object or situation in which exposure to the stimulus produces an immediate anxiety response. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

Group therapy is strongly encouraged, but not mandatory, on an inpatient psychiatric unit. The unit manager's policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager's policy preserve? A. Justice B. Autonomy C. Veracity D. Beneficence

ANS: B The unit manager's policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. The principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that health-care workers must respect these decisions. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

Which risk factor should a nurse recognize as the most reliable indicator of potential client violence? A. A diagnosis of schizotypal personality disorder B. History of assaultive behavior C. Family history of violence D. Recent eviction from a homeless shelter

ANS: B A prior history of assault is the most widely recognized risk factor for client violence. KEY: Cognitive Level: Comprehension| Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

The nurse observes a client's escalating anger. The client begins to pace the hall and shouts, "You all better watch out. I'm going to hurt anyone who gets in my way." Which should be the priority nursing intervention? A. Calmly tell the client, "Staff will help you to control your impulse to hurt others." B. Remove other clients from the area and maintain milieu safety. C. Gather a show of force by contacting security for assistance. D. Calmly tell the client, "You will need to be medicated and secluded."

ANS: B During an emergent situation on an inpatient unit, the nurse's priority action should be to keep all clients safe by removing them from the area of conflict. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A nursing instructor is teaching about the concept of anger. Which student statement indicates the need for further instruction? A. "Anger is physiological arousal." B. "Anger and aggression are essentially the same." C. "Anger expression is a learned response." D. "Anger is not a primary emotion."

ANS: B Further teaching is necessary when the student states that anger and aggression are essentially the same. Anger and aggression are significantly different. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

Once the nurse initiates restraint for an out-of-control 45-year-old patient, what must occur within 1 hour, according to JCAHO standards? A. The patient must be let out of restraint. B. A physician or other licensed independent practitioner must conduct an in-person evaluation. C. The patient must be bathed and fed. D. The patient must be included in debriefing.

ANS: B Joint Commission (JCAHO) standards require that a physician or other licensed independent practitioner conduct an in-person evaluation of the client within 1 hour of the initiation of restraint. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

For select clients, physical restraint is considered to be a beneficial intervention. This is based on which premise? A. Clients with poor boundaries do not respond to verbal redirection, and they need firm and consistent limit setting. B. Clients with limited internal control over their behavior need external controls to prevent harm to themselves and others. C. Clients with antisocial tendencies need to submit to authority. D. Clients with behavioral dysfunction need behavioral interventions.

ANS: B Restraints are used for clients who are unable to control their behavior in order to prevent harming themselves or others. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment

On an inpatient psychiatric unit, a restrained 16-year-old client continues to verbally lash out and threatens to abuse staff and kill self when released. To meet Joint Commission standards, at what time should a nurse expect the physician to renew the client's restraint order? A. Within 1 hour of the original restraint order B. Within 2 hours of the original restraint order C. Within 3 hours of the original restraint order D. Within 4 hours of the original restraint order

ANS: B The Joint Commission (JCAHO) requires that a physician or a licensed independent practitioner reissue a new order for restraints every 4 hours for adults, every 2 hours for adolescents, and every 1 hour for children. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A student nurse has just entered a psychiatric rotation. The student asks a nursing instructor, "How will we know if someone may get violent?" Which is the most appropriate reply by the nursing instructor? A. "You can't really say for sure. There are limited indicators of potential violence." B. "Certain behaviors indicate a potential for violence. They are labeled as a 'prodromal syndrome' and include rigid posture, clenched fists, and raised voice." C. "Any client can become violent, so it is best to be aware of your surroundings at all times." D. "When a client suddenly becomes quiet, is withdrawn, and maintains a flat affect, this is an indicator of potential violence."

ANS: B These behaviors have been identified as predictors of violent behavior. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

An adult client assaults another client and is placed in restraints. Which statement from the client while in restraints should alert a nurse that further assessment is necessary? A. "I hate all of you!" B. "My fingers are tingly." C. "You wait until I tell my lawyer." D. "I have a sinus headache."

ANS: B This statement may mean that the restraints are excessively tight and impeding circulation. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

At 3 a.m., when less restrictive methods fail, a physician orders restraints for an angry, aggressive client. To meet Joint Commission standards, at what time and by whom should a nurse expect an in-person client evaluation? A. No later than 8 a.m., by a licensed independent practitioner or a clinical nurse specialist B. No later than 4 a.m., by a physician or a licensed independent practitioner (LIP) C. No later than 3:30 a.m., by a physician or the client's case manager D. No later than 6 a.m., by the psychiatrist or a clinical nurse specialist

ANS: B To meet Joint Commission standards, an in-person evaluation by a physician or LIP should be conducted within 1 hour of the initiation of restraints. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A nursing instructor is teaching about violence-intervention protocols. Which student statement would indicate the need for further instruction? A. "Administering psychotropic medications can be a part of violence-intervention protocols." B. "Soothing the client by stroking an arm or shoulder can be a part of violence-intervention protocols." C. "Applying leather restraints can be a part of violence-intervention protocols." D. "Calling for assistance is a part of violence-intervention protocols."

ANS: B Touching the client could be seen by him or her as threatening and provoke further violence. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment

How would a nurse differentiate a client diagnosed with a social phobia from a client diagnosed with a schizoid personality disorder (SPD)? A. Clients diagnosed with social phobia can manage anxiety without medications, whereas clients diagnosed with SPD can manage anxiety only with medications. B. Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social phobia are not. C. Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. D. Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social phobias tend to avoid interactions in all areas of life.

ANS: C Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. Social phobia is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

The nurse assesses a client as experiencing maladaptive grieving. Which of the following factors confirms the nurse's assessment? A. The client's spouse died 12 months ago. B. The client still cries when recalling memories of the deceased. C. The client reports feelings of worthlessness. D. The client reports intermittent anxiety.

ANS: C Several authors identify loss of self-esteem as the differentiating factor between normal and maladaptive grieving. The length of time needed to grieve is variable, so it is difficult to establish a time frame as indicative of maladaptive grief. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client diagnosed with schizophrenia states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing reply? A. "Did you take your medicine this morning?" B. "You are not going to hell. You are a good person." C. "I'm sure the voices sound scary. I don't hear any voices speaking." D. "The devil only talks to people who are receptive to his influence."

ANS: C The most appropriate reply by the nurse is to reassure the client with an accepting attitude while not reinforcing the hallucination. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply? A. "Tell him to stop discussing the voices." B. "Ignore what he is saying, while attempting to discover the underlying cause." C. "Focus on the feelings generated by the hallucinations and present reality." D. "Present objective evidence that the voices are not real."

ANS: C The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content. It is inappropriate to present logical arguments to persuade the client to accept the hallucinations as not real. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client is experiencing a severe panic attack. Which nursing intervention would meet this client's immediate need? A. Teach deep breathing relaxation exercises B. Place the client in a Trendelenburg position C. Stay with the client and offer reassurance of safety D. Administer the ordered prn buspirone (BuSpar)

ANS: C The nurse can meet this client's immediate need by staying with the client and offering reassurance of safety and security. The client may fear for his or her life, and the presence of a trusted individual provides assurance of personal safety. KEY: Cognitive Level: Application | Integrated Processes: Implementation | Client Need: Psychosocial Integrity

A brother calls to speak to his sister who has been admitted to the psychiatric unit. The nurse connects him to the community phone and the sister is summoned. Later the nurse realizes that the brother was not on the client's approved call list. What law has the nurse broken? A. The National Alliance for the Mentally Ill Act B. The Tarasoff Ruling C. The Health Insurance Portability and Accountability Act D. The Good Samaritan Law

ANS: C The nurse has violated the Health Insurance Portability and Accountability Act (HIPAA) by revealing that the client had been admitted to the psychiatric unit. The nurse should not have provided any information without proper consent from the client. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment

A client diagnosed with schizophrenia states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom? A. Magical thinking; administer an antipsychotic medication B. Persecutory delusions; orient the client to reality C. Command hallucinations; warn the psychiatrist D. Altered thought processes; call an emergency treatment team meeting

ANS: C The nurse should determine that the client is exhibiting command hallucinations. The nurse's legal responsibility is to warn the psychiatrist of the potential for harm. A client who is demonstrating a risk for violence could potentially become physically, emotionally, and/or sexually harmful to others or to self. KEY: Cognitive Level: Analysis | Integrated Processes: Communication and Documentation; Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

What is the best nursing rationale for holding a debriefing session with clients and staff after clients have witnessed a peer being "taken down" after a violent outburst? A. To reinforce unit rules with the client population B. To create protocols for the future release of tensions associated with anger C. To process feelings and concerns related to the witnessed intervention D. To discuss the client problems that led to inappropriate expressions of anger

ANS: C The nurse should determine that the purpose for holding a debriefing session with clients and staff after clients have witnessed a peer being "taken down" after a violent outburst is to process feelings and concerns related to the witnessed intervention. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom? A. Haloperidol (Haldol) to address the negative symptom B. Clonazepam (Klonopin) to address the positive symptom C. Risperidone (Risperdal) to address the positive symptom D. Clozapine (Clozaril) to address the negative symptom

ANS: C The nurse should expect the physician to order risperidone (Risperdal) to address the positive symptoms of schizophrenia. Risperidone (Risperdal) is an atypical antipsychotic used to reduce positive symptoms, including disturbances in content of thought (delusions), form of thought (neologisms), or sensory perception (hallucinations). KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client living on the beachfront seeks help with an extreme fear of crossing bridges, which interferes with daily life. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this therapy should the nurse convey to the client? A. "Using your imagination, we will attempt to achieve a state of relaxation that you can replicate when faced with crossing a bridge." B. "Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response." C. "Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety." D. "In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate."

ANS: C The nurse should explain to the client that systematic desensitization exposes the client to a series of increasingly anxiety-provoking steps that will gradually increase anxiety tolerance. Systematic desensitization was introduced by Joseph Wolpe in 1958 and is based on behavioral conditioning principles. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)? A. Long-term treatment with diazepam (Valium) B. Acute symptom control with citalopram (Celexa) C. Long-term treatment with buspirone (BuSpar) D. Acute symptom control with ziprasidone (Geodon)

ANS: C The nurse should identify that an appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients with GAD. It takes 10 to 14 days for alleviation of symptoms but does not have the dependency concerns of other anxiolytics. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse assesses a woman whose husband died 13 months ago. She isolates herself, screams at her deceased spouse, and is increasingly restless and aimless. According to Bowlby, this widow is in which stage of the grieving process? A. Stage I: Numbness or protest B. Stage II: Disequilibrium C. Stage III: Disorganization and despair D. Stage IV: Reorganization

ANS: C The nurse should identify that this client is in the third stage of Bowlby's grief process, called disorganization and despair. This stage is characterized by feelings of despair in response to the realization that the loss has occurred. The individual experiences helplessness, fear, and hopelessness. Perceptions of visualizing or being in the presence of the lost individual may occur. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse? A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader

ANS: C The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients in communicating needs and maintaining connectedness. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client diagnosed with brief psychotic disorder tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client? A. Disturbed sensory perception B. Altered thought processes C. Risk for violence: directed toward others D. Risk for injury

ANS: C The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices telling him to kill someone is at risk for responding and reacting to the command hallucination. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

A client who will be receiving electroconvulsive therapy (ECT) must provide informed consent. Which situation should cause a nurse to question the validity of the informed consent? A. The client is paranoid. B. The client is 87 years old. C. The client incorrectly reports his or her spouse's name, the date, and the time of day. D. The client relies on his or her spouse to interpret the information.

ANS: C The nurse should question the validity of informed consent when the client incorrectly reports the spouse's name, date, and time of day. This indicates that this client is disoriented and may not be competent to make informed choices. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

Which situation contradicts the ethical principle of veracity? A. A nurse provides a client with outpatient resources to benefit recovery. B. A nurse refuses to give information to a physician who is not responsible for the client's care. C. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room. D. A nurse treats all of the clients equally regardless of illness severity.

ANS: C The nurse who tricks a client into seclusion has violated the ethical principle of veracity. The principle of veracity refers to one's duty to always be truthful and not intentionally deceive or mislead clients. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the client's wishes? A. When the client makes inappropriate sexual innuendos to a staff member B. When the client constantly demands inappropriate attention from the nurse C. When the client physically attacks another client after being confronted in group therapy D. When the client refuses to bathe or perform hygienic activities

ANS: C The nurse would have the right to medicate a client against his or her wishes if the client physically attacks another client. This client poses a significant risk to safety and is incapable of making rational choices. The client's refusal to accept treatment can be challenged because the client is endangering the safety of others. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to also attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the correctly written priority nursing diagnosis for this client? A. Ineffective coping R/T situational crisis AEB powerlessness B. Anxiety R/T fear of failure C. Risk for self-directed violence R/T hopelessness D. Risk for low self-esteem R/T loss events AEB suicidal ideations

ANS: C The priority nursing diagnosis for this client is "Risk for self-directed violence R/T hopelessness." Nurses should prioritize diagnoses and outcomes on the basis of potential safety risk to the client and/or others. Nursing diagnoses should be correctly written to include evidence if actual and no evidence if the diagnosis is determined to be potential. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

A college student is unable to take a final examination because of severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should a campus nurse assign for this client? A. Noncompliance R/T test taking B. Ineffective role performance R/T helplessness C. Altered coping R/T anxiety D. Powerlessness R/T fear

ANS: C The priority nursing diagnosis for this client is altered coping R/T anxiety. The nurse should assist in implementing interventions that should improve the client's healthy coping skills and reduce anxiety. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid; benztropine (Cogentin), 1 mg prn; and zolpidem (Ambien), 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices

ANS: C The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

The client states, "I get into trouble because I respond violently without thinking. That usually gets me into a mess." Which nursing reply would be most therapeutic to address this client's problem? A. "Everybody loses their temper. It's good that you know that about yourself." B. "I'll bet you have some interesting stories to share about overreacting." C. "Let's explore methods to help you stop and think before taking action." D. "It's good that you are showing readiness for behavioral change."

ANS: C Helping the client to find alternative ways to release tension by more appropriate problem-solving behaviors is a therapeutic nursing intervention. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client diagnosed with paranoid schizophrenia has a history of aggravated assault. A nurse assigns "Risk for other-directed violence" as the client's priority nursing diagnosis. Based on this diagnosis, which would be an appropriate, correctly written outcome for this client? A. The client will not verbalize anger or hit anyone. B. The client will verbalize anger rather than hit others. C. The client will not inflict harm on others during this shift. D. The client will be restrained if verbal or physical abuse is observed during this shift.

ANS: C Preventing injury to others is the appropriate outcome. Outcomes must be client centered, specific, realistic, and measureable and contain a time frame. Answer "A" does not contain a time frame. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment

A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client? A. The client is placed in seclusion. B. The client is placed in a geriatric chair with tray. C. The client is placed in soft Posey restraints. D. The client is monitored by an ankle bracelet.

ANS: D The least restrictive alternative for this client would be monitoring by an ankle bracelet. The client does not pose a direct dangerous threat to self or others, so neither physical restraints nor seclusion would be justified. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

An involuntarily committed client is verbally abusive to the staff and repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit? A. Verbally redirect the client, and then limit one-on-one interaction. B. Involve the hospital's security division as soon as possible. C. Notify the client that documenting personal staff information is against hospital policy. D. Continue professional attempts to establish a positive working relationship with the client.

ANS: D The most appropriate nursing action is to continue professional attempts to establish a positive working relationship with the client. The involuntarily committed client should be respected and has the right to assert grievances if rights are infringed. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia? A. Provide neon lights and soft music. B. Maintain continual eye contact throughout the interview. C. Use therapeutic touch to increase trust and rapport. D. Provide personal space to respect the client's boundaries.

ANS: D The most appropriate nursing intervention is to provide personal space to respect the client's boundaries. Providing personal space may serve to reduce anxiety and thus reduce the client's risk for violence. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

An involuntarily committed client, when offered a dinner tray, pushes it off the bedside table onto the floor. Which intervention should a nurse prioritize to address this behavior? A. Initiate forced medication protocol. B. Help the client to explore the source of anger. C. Ignore the act to avoid reinforcing the behavior. D. With staff support and a show of solidarity, set firm limits on the behavior.

ANS: D The most appropriate nursing intervention is to set firm limits on the behavior. Pushing food onto the floor does not warrant forced medication because the behavior is not a direct safety concern. Exploring the source of anger may be appropriate after the client has gained emotional control. Ignoring the act may further upset the client and does not reinforce appropriate behavior. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" Which potential symptom of this disorder is the nurse assessing? A. Thought insertion B. Paranoia C. Magical thinking D. Delusions of reference

ANS: D The nurse is assessing for the potential symptom of delusions of reference. A client who believes that he or she receives messages through the radio is experiencing delusions of reference. When a client experiences these delusions, he or she interprets all events within the environment as personal references. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which violation of an ethical principle should a nurse recognize in this situation? A. Autonomy B. Beneficence C. Nonmaleficence D. Justice

ANS: D The nurse should determine that the ethical principle of justice has been violated by the physician's actions. The principle of justice requires that individuals should be treated equally regardless of race, sex, marital status, medical diagnosis, social standing, economic level, or religious belief. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment

A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client's problem? A. Distract the client with other activities whenever ritual behaviors begin. B. Report the behavior to the psychiatrist to obtain an order for medication dosage increase. C. Lock the room to discourage ritualistic behavior. D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

ANS: D The nurse should discuss with the client the anxiety-provoking triggers that precipitate the ritualistic behavior. If the client is going to be able to avoid the anxiety, he or she must first learn to recognize precipitating factors. Attempting to distract the client, seeking medication increase, and locking the client's room are not appropriate interventions because they do not help the client recognize anxiety triggers. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A college student who was nearly raped while jogging completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met? A. "You've really been helpful. Can I count on you for continued support?" B. "I don't work out anymore." C. "I'm really glad I didn't go home. It would have been hard to come back." D. "I carry mace when I jog. It makes me feel safe and secure."

ANS: D The nurse should evaluate that the client who has developed adaptive coping strategies has achieved the goals of crisis intervention. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A client diagnosed with schizophrenia, who has been taking antipsychotic medication for the last 5 months, presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome, treated by discontinuing antipsychotic medications B. Agranulocytosis, treated by administration of clozapine (Clozaril) C. Extrapyramidal symptoms, treated by administration of benztropine (Cogentin) D. Tardive dyskinesia, treated by discontinuing antipsychotic medications

ANS: D The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medications. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be an irreversible side effect of typical antipsychotic medications. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client comes to a psychiatric clinic, experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What correctly written long-term outcome is realistic in addressing this client's crisis? A. The client will change his or her type A personality traits to more adaptive ones by week 1. B. The client will list five positive self-attributes. C. The client will examine how childhood events led to an overachieving orientation. D. The client will return to previous adaptive levels of functioning by week 6

ANS: D The nurse should identify that a realistic long-term outcome for this client would be to return to previous adaptive levels of functioning. The nurse should work with the client to develop attainable outcomes that reflect the immediacy of the situation. To be correctly written, an outcome must be client-centered, specific, measurable, realistic, and contain a time frame. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify? A. Sublimation B. Dissociation C. Rationalization D. Intellectualization

ANS: D The nurse should identify that the client is using the defense mechanism of intellectualization when discussing the rituals of obsessive-compulsive disorder in detail while avoiding discussion of feelings. Intellectualization is an attempt to avoid expressing emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

How would a nurse differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? A. GAD is acute in nature, and panic disorder is chronic. B. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. C. Hyperventilation is a common symptom in GAD and rare in panic disorder. D. Depersonalization is commonly seen in panic disorder and absent in GAD.

ANS: D The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A cab driver stuck in traffic is suddenly lightheaded, tremulous, and diaphoretic and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority? A. Generalized anxiety disorder and a nursing diagnosis of fear B. Altered sensory perception and a nursing diagnosis of panic disorder C. Pain disorder and a nursing diagnosis of altered role performance D. Panic disorder and a nursing diagnosis of panic anxiety

ANS: D The nurse should suspect that the client has exhibited signs/symptoms of a panic disorder. The priority nursing diagnosis should be panic anxiety. Panic disorder is characterized by recurrent, sudden-onset panic attacks in which the person feels intense fear, apprehension, or terror. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

Which statement should a nurse identify as correct regarding a client's right to refuse treatment? A. Clients can refuse pharmacological but not psychological treatment. B. Clients can refuse any treatment at any time. C. Clients can refuse only electroconvulsive therapy (ECT). D. Professionals can override treatment refusal if the client is actively suicidal or homicidal.

ANS: D The nurse should understand that health-care professionals can override treatment refusal when a client is actively suicidal or homicidal. A suicidal or homicidal client who refuses treatment may be a danger to self or others. This situation should be treated as an emergency, and treatment may be performed without informed consent. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

A mother is concerned about her ability to perform in her new role. She is quite anxious and refuses to leave the postpartum unit. To offer effective client care, a nurse should recognize which information about this type of crisis? A. This type of crisis is precipitated by unexpected external stressors. B. This type of crisis is precipitated by preexisting psychopathology. C. This type of crisis is precipitated by an acute response to an external situational stressor. D. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.

ANS: D The nurse should understand that this type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. Reassurance and guidance should be provided as needed, and the client should be referred to services that can provide assistance. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

A teenager has recently lost a parent. Which grieving behavior should a school nurse expect when assessing this client? A. Denial of personal mortality B. Preoccupation with the loss C. Clinging behaviors and personal insecurity D. Acting-out behaviors, exhibited in aggression and defiance

ANS: D The school nurse should anticipate that this teenager would exhibit aggression and acting-out behaviors. Adolescents have the ability to understand death on an adult level yet have difficulty tolerating the intense feelings associated with the death of a loved one. It is often easier for adolescents to express sorrow by acting out rather than typical emotional expressions of the grieving process. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nurse is caring for four clients. Which client should the nurse identify as least prone to developing problems with anger and aggression? A. A child raised by a physically abusive parent B. An adult with a history of epilepsy C. A young adult living in the ghetto of an inner city D. An adolescent raised by Scandinavian immigrant parents

ANS: D An adolescent raised by Scandinavian immigrant parents would be least prone to developing problems with anger and aggression as compared with the other clients presented. A history of abuse, epilepsy, overcrowding, and poverty all contribute as predisposing factors to anger and aggression. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client is served divorce papers while on the inpatient psychiatric unit. When a nurse tells the client the unit telephone cannot be used after hours, the client raises his fists, swears, and spits at the nurse. Which negative coping mechanism has the client exhibited? A. The defense mechanism of projection B. The defense mechanism of reaction formation C. The defense mechanism of sublimation D. The defense mechanism of displacement

ANS: D Anger can lead to aggression when the coping response is displacement. This client has discharged anger against a person (the nurse) unrelated to the true target of the anger (the spouse). KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

After restraints are removed from a client, the staff discusses the incident and establishes guidelines for the client's return to the therapeutic milieu. Which unit procedure is the staff implementing? A. Milieu reenactment B. Treatment planning C. Crisis intervention D. Debriefing

ANS: D Debriefing is an important part of restraint/seclusion. It allows the staff an opportunity to review and learn from the experience and to express feelings generated by the incident. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care

After less restrictive means have been attempted, an order for client restraints has been obtained for a hostile, aggressive 30- year-old client. If client aggression continues, how long will the nurse expect the client to remain in restraints without a physician order renewal? A. 1 hour B. 2 hours C. 3 hours D. 4 hours

ANS: D The Joint Commission (JCAHO) requires that a physician or licensed independent provider (LIP) must reissue a new order for restraints every 4 hours for adults, every 1 hour for clients younger than 9, and every 2 hours for clients 9 to 17 years. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A client diagnosed with brief psychotic disorder is pacing the milieu and occasionally punches the wall. Which should be the initial nursing action? A. Assertively instruct the client to stop punching the wall. B. Encourage the client to write down feelings in a journal. C. With the help of staff, initiate seclusion protocol. D. Ensure adequate physical space between the nurse and the client.

ANS: D To maintain a safe environment, it is important to initially assure that there is adequate physical space between the nurse and the client. Violence can be related to increased contact and decreased defensible space. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment