unit 7

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?"

A client who has successfully adjusted to a colostomy declines the invitation to speak to a support group on the subject of alteration in body image; the client reports an extreme fear of public speaking. The nurse analyzes this information and determines that the client's fear would be considered which diagnosis?

A social phobia

A client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has which?

Agoraphobia

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse should encourage the client to attend which community group?

Alcoholics Anonymous

The nurse is caring for a client with anorexia nervosa. The nurse planning care for the client recognizes that which manifestation is likely to be present?

Amenorrhea

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.

While providing one-to-one supervision, a client who attempted suicide tells the nurse, "I can never do anything right. I'm such a loser. It didn't even work when I tried to kill myself." Which is the appropriate nursing response

You don't think you can ever do anything right?"

A client is scheduled to have electroconvulsive therapy (ECT). Which problem should the nurse include in the plan as a priority?

Risk for aspiration

During a nursing interview, a client says, "My daughter was murdered in her New York apartment, and her estranged husband called to tell me. I can't stop myself from wondering if he killed her, but the police have ruled him out as a suspect." Which statement reflects a therapeutic nursing response?

"Have you shared your concerns with the police?"

The nursing student is developing a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which incorrect intervention in the plan?

Observe for excessive exercise.

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 reviews the treatment prescribed for a client with a mental health disorder. The nurse understands that a form of psychotherapy in which the client enacts situations that are of emotional significance is identified by which term?

Psychodrama

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which?

Conversion disorder

A client has a history of seizures. The health care provider has prescribed amitriptyline three times daily. The nurse seeks clarification of the prescription, knowing that the client is at risk for injury because of which adverse effect of the amitriptyline?

Decreased seizure threshold

The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse understands that these types of delusions are characteristic of which?

The false belief that one is being singled out for harm by others

The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. The appropriate nursing intervention is which?

Sit beside the client in silence and verbalize occasional open-ended questions.

The nurse having strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is likely to react to a disagreement with this fellow employee by which action?

Telling a friend that this employee hates her

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 manic client is placed in a seclusion room after an outburst of violent behavior, including physical assault on another client. As the client is secluded, which action should the nurse perform?

Inform the client that she is being secluded to help regain control of herself.

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.

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 is assisting with the data collection on a client admitted to the psychiatric unit. After review of the data obtained, the nurse should identify which as a priority concern?

The client's report of self-destructive thoughts

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?"

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 caring for a client who is receiving lithium carbonate (Lithobid) for the treatment of bipolar disorder and monitors the client for signs of lithium toxicity. Which sign should alert the nurse to the potential for toxicity?

Vomiting