UWorld Mental Health

The nurse is planning care for an 11-year-old child with attention deficit hyperactivity disorder who is hospitalized for surgical treatment of a fractured femur. What is the priority nursing action?

1. Create a structured and consistent environment with a daily schedule The key nursing intervention to help a school-aged child with ADHD adjust to hospitalization is providing a structured, organized, and consistent environment with a daily schedule. A structured environment can help the child plan time for schoolwork, which helps prevent falling behind during periods of unattendance. A structured environment also helps the child organize activities and know what to expect each day (Option 1).

The nurse is caring for a client with bulimia nervosa. Which time period would be most important for the nurse to monitor the client's behavior?

1. During 1-2 hours after each meal The behavior of clients with bulimia nervosa typically consists of binge eating followed by inappropriate behavior to prevent weight gain, such as self-induced vomiting, exercise, and/or excessive use of laxatives. Although it is important to provide one-on-one supervision to a client with bulimia nervosa during every meal, it is most important to monitor the client's activities for 1-2 hours after each meal to prevent self-induced vomiting (Option 1).

The nurse is caring for a client with paranoid personality disorder. When the nurse directs the client to go to the dining room for dinner, the client says, "And eat that poisonous food? You better not make me go anywhere near that room." Which statement best explains the client's behavior?

2. The client has an intense need to control the environment Individuals with paranoid personality disorder have a pervasive distrust and suspicion of others; they believe that people's motives are malicious and assume that others are out to exploit, harm, or deceive them. These thoughts permeate every aspect of their lives and interfere with their relationships. Individuals with paranoid personality disorder are usually difficult to get along with as they may express their suspicion and hostility by arguing, complaining, making sarcastic comments, or being stubborn. Because these clients do not trust others, they have a strong need to be self-sufficient and maintain a high degree of control over their environment (Option 2).

The nurse suspects that the client is experiencing posttraumatic stress disorder. Which of the following symptoms are consistent with this condition?

2.Flashbacks 3.Hypervigilance 4.Irritability 5.Nightmares 6.Self-blame Posttraumatic stress disorder (PTSD) is a reaction to a traumatic event in which physical integrity or sense of self was threatened or harmed. Clients with PTSD reexperience traumatic events (eg, nightmares, flashbacks), experience negative thinking (eg, self-blame), and have increased anxiety and arousal (eg, hypervigilance, insomnia, irritability).

A spouse brings a client with a history of previous suicide attempts to the emergency department due to erratic behavior and expressions of hopelessness. When the triage nurse asks if the client is having suicidal thoughts, the client shrugs their shoulders. What action should the triage nurse take? Frequent observation is not sufficient for a client who may be suicidal.

3. Place the client on one-to-one observation hen caring for a client with significant risk factors for suicide who is unable to verbalize that they are not suicidal, the nurse should ensure client safety and place the client on one-to-one observation until further evaluation is complete. Establishing a therapeutic relationship is essential to promote trust and respect and to allow for the client to disclose potential suicidal ideatio

The nurse is planning a staff education program about intimate partner violence. Which of the following information should the nurse include? Select all that apply.

3. The abusive partner often demonstrates jealousy and possessiveness." 4."Victims may not leave due to financial concerns or fear of harm by the abuser." 5."Violence against a female often intensifies during pregnancy." Intimate partner violence (IPV) is abusive behavior inflicted by one partner against the other in an intimate relationship. IPV occurs in all religious, socioeconomic, racial, and educational groups, and in both heterosexual and same-sex partnerships. IPV often begins or intensifies during pregnancy. Victims often stay in the relationship due to fear, financial or child custody concerns, or religious beliefs, among other reasons

The nurse is leading a support group for partners of military veterans who have posttraumatic stress disorder (PTSD). The nurse explains that most clients with PTSD experience which symptoms?

4. Reliving the event and feeling detached from others Major features of posttraumatic stress disorder include experiencing increased anxiety/emotional arousal (insomnia, irritability, outbursts of anger or rage, difficulty concentrating, hypervigilance, and exaggerated startle response), avoiding reminders of the trauma, and reexperiencing the traumatic events

The nurse should be most concerned that the client will develop which complication?

4. Seizures The nurse recognizes that the greatest risk in tricyclic antidepressant (TCA) overdose is cardiac arrest from cardiotoxicity because TCAs cause QRS interval and QT prolongation that can progress to life-threatening arrhythmias (eg, ventricular tachycardia or fibrillation). The client's cardiac status requires continuous monitoring for evidence of dysrhythmias

The nurse is caring for a client with a history of heroin use. Which clinical finding may indicate withdrawal? Opioid use typically causes constipation, constricted pupils, and drowsiness due to its central nervous system depressant effects.

4. Tachycardia Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids are abruptly stopped, dosage is reduced, or a reversal agent (ie, naloxone) is administered. Withdrawal symptoms (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous system activity as the depressant effect of the opioid wanes (Option 4).

The nurse plans care for a client newly admitted with obsessive-compulsive disorder who is repeatedly counting magazines in the commons room. Which of the following should the nurse include in the initial plan of care? Select all that apply.

1. Assist the client to identify circumstances that increase anxiety 2.Provide positive feedback when the client attends a group activity 3.Refrain from judgmental comments about counting magazines 5.Teach the client how to use the technique of thought stopping (CBT) Educational objective:Obsessive-compulsive disorder is characterized by persistent, intrusive thoughts (obsessions) and behaviors performed ritualistically and repetitively to try to reduce anxiety (compulsions). Nursing care includes assisting the client to identify anxiety-producing situations, allowing time for the ritualistic behavior (initially), remaining nonjudgmental, offering positive feedback, and providing cognitive-behavioral therapy. Suddenly denying the client the ability to perform the ritualistic activity can cause panic-level anxiety. Instead, the nurse should gradually limit the time allotted to the ritualistic behavior, once the client is equipped with new coping mechanisms

Clients with narcissistic personality disorder often behave in grandiose and entitled ways, believe that they are perfect, and rely on constant reinforcement and admiration from people perceived as ideal. What is the best explanation for these clinical characteristics? Narcissistic personality disorder (NPD) is characterized by a recurrent pattern of grandiosity, the need for admiration, and lack of empathy. Clients with NPD are hypersensitive to criticism and may project superiority, arrogance, and independence to hide their true sense of self. Narcissistic traits often derive from a distorted view of oneself that develops from childhood neglect or criticism.

1. Clients are attempting to regulate self-esteem Clients with NPD often experience extremely fragile levels of self-esteem. These individuals develop characteristics of self-importance to protect themselves, to regulate self-esteem, and to avoid feelings of fear or abandonment. Characteristics of NPD are rigid and pervasive because clients often lack the understanding that these traits are problematic (Option 1).

The nurse plans care for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. Which client outcome should the nurse prioritize? Anorexia nervosa is an eating disorder characterized by distorted body image, profound fear of weight gain, a strong desire to be thin, and being unwilling to maintain a healthy body weight. The client engages in behaviors to lose weight, including not eating, purging, extreme exercise, and the use of laxatives and diet pills. Psychosocial issues leading to anorexia are the focus of ongoing therapy, usually on an outpatient basis. However, certain criteria to consider for hospitalization include body weight below 75% of ideal, suicidal behavior, or medical conditions resulting from starvation.

3. Increases caloric intake to gain weight The priority focuses during inpatient care are the short-term outcomes of restoring caloric intake, promoting gradual weight gain, and treating medical conditions caused by starvation (Option 3).

The nurse is caring for a 10-year-old client diagnosed with attention deficit hyperactivity disorder. The client is at risk for which complication? . Symptoms are typically persistent and can lead to impaired social skills and peer rejection, resulting in feelings of isolation and poor self-esteem.

3. Low self-esteem Children may struggle to control impulsive behavior and exhibit emotional dysregulation (eg, low frustration tolerance, irritability, anger outbursts) when unable to meet demands and challenges. Symptoms are typically persistent and can lead to impaired social skills and peer rejection. This results in feelings of isolation and low self-esteem (Option 3).

The nurse on the mental health unit receives report on a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom? Other types of delusions include: Grandeur: "I need to get to Washington for my meeting with the president." Control: "Don't drink the tap water. That's how the government controls us." Nihilistic: "It doesn't matter if I take my medicine. I'm already dead." Somatic: "The doctor said I'm fine, but I really have lung cancer."

3. That song is a message sent to me in secret code." Delusions are a positive symptom of schizophrenia; they are false beliefs that have no basis in reality and are unrelated to a client's culture or intelligence. Delusions of reference cause clients to feel as if songs, newspaper articles, and other events are personal to them.

The nurse is talking with a client with obsessive-compulsive personality disorder who is scheduled for a colonoscopy. Due to a computer malfunction, the procedure is being postponed by 2 hours. Which of the following responses by the client would be consistent with obsessive-compulsive personality disorder?

4. "This is unacceptable. I had my whole day planned out and I cannot change my plan Clients with obsessive-compulsive personality disorder are typically strong-willed, perfectionistic, and punctual. These individuals pay close attention to rules and regulations and have an intense need to control both internal and external experiences. These traits are very extreme and result in rigidity and inflexibility. In this scenario, a change has been made in the client's schedule for the day and is outside the client's control. This could cause significant distress and impaired functioning so that the client feels emotionally paralyzed (Option 4).

A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to the nurse, "The voices are bad today. They are so angry with me." What is the best response by the nurse? An antianxiety medication may be needed if the voices are causing this client to become increasingly distressed. Assessment is needed before choosing this option.

4. "What are the voices saying to you?" Hallucinations are false sensory perceptions that have no external stimuli. The priority nursing action is to explore the content of the hallucinations. This client may be experiencing command auditory hallucinations that could lead to self- or other-directed injury and harm (Option 4).

The new nurse is providing teaching to a client scheduled for electroconvulsive therapy (ECT). What information given by the new nurse would cause the charge nurse to intervene? Although the exact mechanism is unknown, 15-20-second seizures are proven effective in treating mood disorders (eg, major depression, bipolar disorder) and schizophrenia Post-treatment nursing care includes monitoring vital signs, ensuring a patent airway, assessing mental status, and providing frequent reorientation during periods of postictal confusion.

1. "Be sure to take your valproic acid prior to the procedure." (Option 1) Valproic acid (Depakote) is an anticonvulsant that is also prescribed for bipolar disorder; therefore, it would prevent the therapeutic effect of ECT. Any prescribed anticonvulsants should be discontinued prior to ECT. Prior to the procedure, the client should be NPO and not take anticonvulsant medications. Temporary confusion and memory loss are common after the procedure. Clients should be instructed not to drive during the course of ECT treatment.Anesthesia (eg, methohexital, propofol) and a muscle relaxant (eg, succinylcholine) will be administered; clients are unconscious and feel no pain during the procedure.

The home-health nurse is assessing a client who reports severe anxiety associated with riding in a train for a new job. The nurse recognizes that the client most likely has what disorder? 2.Generalized anxiety disorder 3.Social anxiety disorder 4.Zoophobia

1. Agoraphobia Clients with agoraphobia have intense fear and anxiety about being in certain situations or spaces. These clients are highly concerned about having trouble escaping or getting help in the event of a panic attack. This fear is out of proportion to any actual danger (Option 1). In severe agoraphobia, the client often prefers not to leave the home and avoids public places for fear of recurring panic attacks or embarrassment. Clients with agoraphobia actively avoid these situations and often feel the need to be accompanied by a relative or friend if avoidance is impossible. Such clients experience fear and anxiety while in the following situations: - Public transportation (eg, bus, train) - Open spaces (eg, stores, bridges, parking lots) - Enclosed places (eg, movie theaters, stores) - Crowds or standing in line - Outside the home alone

The nurse is caring for a client who is experiencing active suicidal ideation. Which of the following interventions are appropriate? Select all that apply. (Option 4) Discharging a client who has active suicidal ideation is not appropriate because of the risk for self-harm. An intensive outpatient program will likely be indicated once the client's condition is stable (eg, absence of suicidal ideation).

1. Conduct a suicide risk assessment 2.Perform mouth checks during medication administration 3.Place the client on one-to-one observation 5. Remove the client's necklace and shoelaces

The nurse at a mental health clinic is performing a suicide risk screening on four clients experiencing depression. Which client does the nurse recognize as being most at risk for suicide? (Option 2) The client who has depression and breast cancer has 2 known risk factors. The daughter's divorce may be a significant loss or stressor, adding another risk factor. However, marriage is a protective factor against suicide.

1. Divorced male client with Parkinson disease who was recently laid off from his job In addition to depression, the divorced male client with Parkinson disease and recent job loss is the most at risk for suicide, with 5 risk factors (Option 1).

Which client finding requires immediate follow-up by the nurse?

1. Hopelessness Clients who express hopelessness are at significant risk for suicide. This client has several risk factors for suicide, including a stressful life event (eg, death of sibling), recent job loss, impulsivity, and substance use. Alcohol and benzodiazepine (sedative) use are strongly associated with increased suicide risk because of the disinhibiting effects of intoxication. Additional factors include the client's guilt and loss of interest. Therefore, a suicide risk assessment is the immediate priority. The nurse should ask the client targeted questions regarding any suicidal thoughts, intent, means, or plan (Option 1).

A client with moderate Alzheimer disease is started on Memantine/Namenda In evaluating the effectiveness of this medication, what should the nurse assess for in the client? Memantine is used to ease the symptoms of moderate to severe Alzheimer disease (AD), thereby improving the quality of life for clients and caregivers. Memantine is an N-methyl-D-aspartate (NMDA) antagonist that works by binding to NMDA receptors, blocking the brain's NMDA glutamate pathways, and protecting brain cells from overexposure to glutamate (excess levels of glutamate contribute to brain cell death). Memantine delays but does not stop the progression of some symptoms of moderate to severe AD.

1. Improved ability to perform activities of daily living Clients with moderate to severe AD may experience improvement in: - Cognition: Memory, thinking, language - Daily functioning: Dressing, bathing, grooming, eating (Option 1) - Behavioral problems: Agitation, depression, hallucinations

The nurse on the mental health unit receives report on 4 clients. Which client should the nurse see first? Clients with PTSD commonly experience a cluster of symptoms that include: Mood symptoms (eg, loss of pleasure in activities, negative belief about self or others) Hyperarousal symptoms (eg, irritability, hypervigilance, impulsivity, insomnia, trouble concentrating) Avoidance symptoms (eg, avoidance of distressing thoughts associated with the traumatic event) Intrusive symptoms (eg, memories, intrusive thoughts, flashbacks) Clients experiencing acute mania can function with minimal to no sleep for several days. Clients with major depression often exhibit vegetative symptoms (eg, decreased libido, sleep disturbances, appetite and weight fluctuations). Following up on the client's decreased appetite is important; however, assessing for suicide is the priority.

2. Client diagnosed with posttraumatic stress disorder who reports a depressed mood and feelings of hopelessness Feelings of hopelessness related to the symptom cluster can lead clients to believe that attempting suicide is the only way out of their misery. The nurse should follow up on feelings of hopelessness and conduct a suicide assessment (Option 2).

The nurse is caring for a client admitted with abdominal pain, who has been diagnosed with somatic symptom disorder after a thorough evaluation finds no medical cause for the symptoms. Which intervention should the nurse include in the plan of care? Somatic symptom disorder (SSD) is a psychological disorder that develops from stress, resulting in medically unexplainable physical symptoms (eg, abdominal pain) that disrupt daily life. Clients with SSD focus an excessive amount of time, thought, and energy on the symptoms, often seeking medical care from multiple health care providers. Nursing interventions focus on minimizing indirect benefits and developing client insight.

2. Limit time spent discussing physical symptoms with the client To minimize the indirect benefits from being "sick" (secondary gains), the nurse should: - Redirect somatic complaints to unrelated, neutral topics - Limit time spent discussing physical symptoms (Option 2) To promote insight and healthy coping mechanisms, the nurse should assist the client to: - Identify secondary gains (eg, increased attention, freedom from responsibilities) - Recognize factors that intensify symptoms (eg, increased stress, reminders of a deceased family member) - Incorporate appropriate coping strategies (eg, relaxation training, physical activity)

Which of the following situations would most likely cause a client with social anxiety disorder to seek therapy at the local community mental health center? Social anxiety disorder (SAD) is characterized by an excessive and persistent fear of social or performance situations in which the client is exposed to strangers and the possibility of scrutiny by others. Examples of such social interactions include meeting unfamiliar people, being observed eating or drinking in public, and giving a speech. The client may fear criticism, embarrassment, humiliation, and rejection from unfamiliar people in unfamiliar social situations and will exhibit physical symptoms of anxiety such as sweating, trembling, palpitations, diarrhea, and blushing. Seeing a new health care provider can cause some degree of discomfort in a client with SAD; however, as a one-on-one encounter, it is not likely to cause severe anxiety or panic.

2. The client's boss has asked the client to speak at an upcoming convention

The emergency department nurse cares for a client whose college roommate reports recent changes in the client's behavior. Which behaviors and clinical data meet the criteria for involuntary admission to the mental health unit? Select all that apply.

2.Client has refused food and water for 4 days and has poor skin turgor 3.Client repeatedly mumbles, "I must kill them before they get me" The legal criteria for involuntary admission include: - The individual appears to be an imminent danger to self or others (Option 3). - The individual has a grave disability (ie, is unable to adequately care for basic needs [food, clothing, shelter, medical care, personal safety]) as a result of a mental illness (Option 2). Clients also have the right to the least restrictive environment in which treatment can be provided in a safe manner. Involuntary commitment is generally used as a last resort in dealing with a client whose illness is so severe that judgment and insight in deciding to refuse treatment are markedly impaired.

The nurse is teaching the parent of a 7-year-old client with newly diagnosed attention deficit hyperactivity disorder. Which statement by the parent would require follow-up?

3. "My child will outgrow this condition and be fully recovered by adulthood." Attention deficit hyperactivity disorder (ADHD) is characterized by symptoms of inattention, distractibility, impulsivity, and hyperactivity. Symptoms usually continue into adulthood; current research indicates that children do not outgrow the condition (Option 3). However, clients with ADHD learn to cope with and manage their symptoms, enabling them to lead healthy and satisfying lives. Clients may move into a state of being "recovered," but this is usually a dynamic and ongoing process.

Which statement by a client with a diagnosis of dependent personality disorder would the nurse recognize as progress toward a positive therapeutic outcome? Individuals with dependent personality disorder have a persistent and extreme need to be taken care of that manifests as submissive and clinging behaviors and fear of separation. Clients with dependent personality disorder will often express appreciation or make flattering comments to the nurse/therapist to gain approval.

3. "My parents could not drive me here today, so I took the bus." Additional characteristics of dependent personality disorder may include: - Difficulty in making day-to-day decisions - An excessive need for advice, reassurance, and nurturance from others - Lack of self-confidence; afraid to do things on one's own - Afraid of confrontation or expressing disagreement with others - Feelings of helplessness and anxiety when alone; fear of being unable to take care of oneself A client making a decision about and carrying out a daily activity on their own would be indicative of progress toward a therapeutic outcome (Option 3).

The nurse is managing the care of a client diagnosed with generalized anxiety disorder. What behavior demonstrates that the client is building resiliency and an improvement in anxiety symptoms? Resilience is a protective factor that is strengthened by practicing positive coping skills (eg, deep breathing, journaling, muscle relaxation).

3. Practices stress reduction techniques daily Identifying anxiety-inducing triggers is helpful; however, the individual must take action to deal with both the origin and response to the particular stressor.

A client recently diagnosed with schizophrenia is brought to the behavioral health clinic by the identical twin sibling for the first follow-up visit after hospitalization. The client's sibling says to the nurse, "I read that schizophrenia runs in families. I guess I'm doomed." What is the best response by the nurse?

4. "You are at risk for the disease. However, there are other factors that contribute to the development of schizophrenia." There are several factors and theories that contribute to the development of schizophrenia. When communicating with a family member about risk factors, the nurse should acknowledge the family member's concerns, provide useful information, and encourage further discussion.

The nurse is trying to comfort a client who is crying in the group room. The client states, "I just don't know what to do about this situation with my parents," and the nurse replies, "I'm sure you will do the right thing." What summary is true regarding the nurse's response?

4. The response devalues the client's feelings and gives false reassurance Giving false reassurance is a nontherapeutic communication technique that can negatively affect the nurse-client relationship. A nurse who does not acknowledge a client's feelings and gives the impression that there is nothing to worry about devalues the client's concerns. This technique blocks a therapeutic conversation because the client may feel that verbalization of additional concerns or feelings will also be devalued (Option 4).

The nurse cares for a client newly diagnosed with acute stress disorder following a traumatic event. Which of the following communications by the nurse are appropriate? Select all that apply. Acute stress disorder (ASD) occurs following a traumatic or extremely stressful event. ASD is characterized by intrusive memories of the event, negative mood, dissociative symptoms (eg, altered sense of reality), and arousal and reactivity symptoms (eg, hyperactive sensory state, sleep disturbances, difficulty concentrating, easily startled). If these symptoms continue beyond a month after the event, the diagnosis becomes post-traumatic stress disorder. Nursing interventions for a client with ASD include:

1. "How has this situation affected your relationships with family and friends?" 3."It is normal to experience difficult symptoms after a traumatic event." 4."Please tell me about your current use of alcohol and any drugs." 5."Share with me any thoughts or plans of self-harm that you have had." Clients with acute stress disorder (ASD) should be encouraged to discuss the traumatic event and explore the associated feelings. The nurse should validate the client's feelings; assess risk for self-harm and ineffective coping (eg, drug and alcohol use); and evaluate the impact of ASD on the client's sleep, occupation, and relationships.

A client with obesity reports several failed attempts at weight loss. Which client statement best indicates that the client is ready and motivated for successful weight loss?

1. "I have signed up to be a dog walker when I normally would watch television - Action: The client has firmly committed to changing, has developed a plan (eg, dietary modifications, exercise plans), and actively takes steps toward new behavior (eg, choosing activity over television) (Option 1). Contemplation: The client recognizes a change is needed but is undecided whether it would be possible or worthwhile (Option 2). - "I understand that losing weight would improve my health and well-being." (

The emergency nurse is caring for a female survivor of sexual assault. Which of the following actions should the nurse take? Select all that apply. Emergency nursing care of sexual assault survivors includes determining whether physical evidence has been compromised (eg, shower, bath, douche), and inquiring about that date of the last menstrual period and the use of birth control. The nurse should assess the client's readiness for a pelvic examination, thoroughly document all physical injuries on a body map, and provide prophylactic medication for sexually transmitted infections.

1. Assess the client's readiness for a pelvic examination 2.Determine if the client has douched or had a bath or shower since the incident 3.Inquire about the date of the last menstrual period and the use of birth control 4.Perform head-to-toe assessment of injuries and document injury locations 5.Provide prescribed prophylactic medication for sexually transmitted infections

An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation, confusion, and disorientation to time and place. What is the most important nursing action? This client is experiencing impairment in cognitive and psychomotor functioning and most likely has delirium brought on by the urinary tract infection. This is not an uncommon occurrence in older adult clients. It is important for this client to be well hydrated; this can best be accomplished through IV fluids and electrolyte replacement but NOT by encouraging the client to increase fluid intake. In addition, client safety is the priority. Clients who are agitated often try to get out of bed, even if it means climbing over the side rails. Keeping the bed elevated and side rails raised increases the risk of a fall or other injury if the client attempts to leave the bed.

3. Providing one-on-one supervision The client's most immediate needs are safety and prevention of physical injury. Initially, the client should be placed in a room near the nurses' station with one-on-one supervision and frequent reorientation to time, place, and situation (Option 3). As the condition improves, the client will continue to require frequent observation.

What complication of schizophrenia should the nurse be most concerned about? Mood disorders (eg, anxiety, depression) are common in clients with schizophrenia but the risk for self-harm is more concerning

3. Self-harm Self-harm (eg, suicide) is the most concerning complication of schizophrenia. Clients with schizophrenia have a much higher rate of suicide than the general population. Possible contributing factors include anhedonia (ie, inability to experience pleasure) and attempting to escape frightening or disturbing hallucinations. The nurse should assess clients with schizophrenia for self-harm, especially in the presence of altered perception (eg, hallucinations, delusions Clients experiencing acute psychosis also pose a danger to others during an agitated state (eg, yelling, throwing objects) and are at high risk of continuing to act violently in response to paranoid delusions (eg, "You are all trying to poison me!").

The nurse cares for a client who has a do-not-resuscitate prescription, and notes extensive skin mottling and vital signs consistent with impending death. The client's spouse states, "I hope my spouse can hang on a little longer; our anniversary is in 2 days." What response by the nurse is appropriate?

4. "Your spouse's body is shutting down and the time is near; I will stay here with you." End-of-life care includes providing psychosocial support to the client's family members and assisting them through the dying process. This is accomplished by providing factual, open, and honest communication while conveying empathy. The nurse can reduce family members' fear and anxiety by helping them anticipate what to expect as death becomes imminent, while using the therapeutic communication technique of offering self (Option 4).

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Selective serotonin reuptake inhibitors (SSRIs) (eg, escitalopram, fluoxetine) are commonly used to treat MDD and work by increasing the availability of serotonin in the brain.

Potential Conditions: Major depressive disorder Actions to take: Create a safety plan, Administer PO escitalopram, Parameters: Presence of a plan of suicide, sudden improvement of mood Major depressive disorder is characterized by a persistent change in mood or loss of interest in daily activities. Management includes creating a safety plan and monitoring for suicidal ideation. Clients taking selective serotonin reuptake inhibitors (eg, escitalopram) should be monitored for a sudden improvement in mood.

Which of the following actions would the nurse include in planning care for a client with bipolar disorder who is hospitalized for an acute manic episode? Select all that apply. The client experiencing an acute manic episode needs reduced environmental stimuli. Eating with other clients in the dining room would be too stimulating and could exacerbate psychomotor activity. The client with acute mania is easily distractible and would not be able to focus on planning an activity. The client with acute mania is not ready to participate in group activities.

1. Assign the client to a private room 3. Have the client participate in physical exercise with a staff member The care plan for a client experiencing an acute manic episode includes the following: - Maintaining a low-stimuli environment (eg, quiet area, low lighting, private room, one-on-one activities) to decrease anxiety (Option 1) - Promoting physical activity to help relieve excess energy (Option 3) - Adhering to a structured schedule of activities to help the client focus - Providing high-protein, high-calorie meals and snacks that are easy to eat - Setting limits on behavior by using a firm communication approach

The need for further IV fluid administration is determined based on the client's ____, _____, and _____ The wide QRS complex and temperature are a result of the TCA overdose and should resolve as the body clears the circulating drug

1. Heart rate 2. Urine output 4. Blood pressure The need for further IV fluid administration is determined based on the client's heart rate, blood pressure, and urine output. This client's urine output of 500 mL is likely due to urinary retention from previously formed urine; further urine formation depends only on the cardiac output and renal blood flow.

A client on the locked unit of an inpatient psychiatric hospital says to a nurse on the night shift, "During the day they made an exception and let me go to the cafeteria. You're my favorite nurse; I know you'll be nice to me and let me go get a snack again." What is the best response by the nurse? Clients with borderline and antisocial personality disorders, substance use disorder, and bipolar disorder often display manipulative behavior that is aimed at gaining control and power over a person or situation for personal gratification. Clients manipulate through flattery or by staff splitting. Clients may use false information to "tell on" a staff member or act in a way that gives the impression of sincerity and caring towards staff members for personal gain.

4. "You do not have privileges for leaving the unit at this time. Nursing interventions include setting behavioral limits, using a neutral tone when discussing rules and the consequences of unacceptable behavior, and ensuring consistency from staff members in enforcing limits.

The mental health clinic nurse is evaluating the treatment plan for a client with obsessive-compulsive disorder who counts backward from 5 to 1 many times a day. Which of the following client statements indicates progress toward effective coping? Select all that apply. Obsessive-compulsive disorder is characterized by obsessions and/or compulsions engaged in to relieve anxiety. Treatment effectiveness is demonstrated by the client's ability to identify situations that increase anxiety and develop healthy coping techniques to manage anxiety (eg, deep breathing, exercise) that replace the ritualistic behaviors.

2. "Having a heavier workload increases my anxiety and the urge to count, but I calm myself with deep-breathing exercises." 3."I used to start counting as soon as I boarded the bus, but now I can ride for 30 minutes without counting." 5. "When I begin feeling anxious, I take a short, brisk walk so I can decompress and refocus."

The nurse speaks with a client diagnosed with schizophrenia who begins to look away toward the door and grimace. Which response by the nurse is most therapeutic at this time?

3. "What do you see at the door? The nurse should be aware of client cues that indicate hallucinations (distraction, mumbling, watching a vacant area of the room). This client might be having a visual hallucination, as evidenced by being distracted and grimacing. The nurse must assess for hallucinations that might direct or cause the client to be unsafe or aggressive (eg, suicidal or homicidal themes). It is most therapeutic to ask the client what is being sensed (eg, seen, heard, smelled, tasted, felt). Once the specifics of the hallucination are known, the nurse can help the client properly cope with the situation (Option 3).

A client with anorexia nervosa was admitted to the inpatient behavioral health unit 10 days ago. During a weight check-in, the client realizes a 2-lb weight gain. The client says to the nurse in a distressed voice, "This is terrible. I'm so fat." What is the best response by the nurse?

3. "You are making progress toward a healthy weight. What are you most worried about? When caring for a client with AN, the nurse should maintain a neutral, empathetic attitude and reinforce the client's goal of obtaining a healthy weight while addressing the client's underlying fears (eg, loss of control, lack of self-worth) (Option 3).

The emergency department nurse cares for a client with multiple bruises, a possible arm fracture, and a facial laceration. The client's spouse is at the bedside and appears angry. Which action is the priority at this time? Notifying social services of suspected abuse should occur with the client's permission after any immediate threats are removed and after physiological needs are met. This should not be done in the presence of any potential abusers.

3. Have the spouse leave the room so that the client can be spoken with and examined in private The priority for possible domestic abuse victims is to remove them from any sources of immediate danger, including suspected abusers. Such clients should be questioned and assessed alone so that the suspected abusers do not guide their answers or intimidate them from providing truthful responses. In this case, the spouse appears angry and should, as a priority, be removed from the room to prevent further potential harm to the client or staff (Option 3).

A client with antisocial personality disorder was given a 2-hour pass to leave the hospital. The client returned to the unit 15 minutes past curfew and did not sign in. The next day, this behavior is brought up in a group meeting. The client says, "It's all the nurse's fault. The nurse was right there and did not remind me to sign in." What is the best response by the nurse? Clients with antisocial personality disorder often disregard rules, have a history of irresponsible behavior, and blame others for their behavior. They avoid responsibility for their own behavior and the consequences of their actions using numerous excuses and justifications.

3. It is your responsibility to sign in when you return from a pass." Nursing interventions include setting firm limits and making clients with antisocial personality disorder aware of the rules and acceptable behaviors. The nurse should require the client to take responsibility for their own behavior and the consequences of not following the rules and regulations of the unit (Option 3).

A client with borderline personality disorder says to the nurse, "You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you." What is the priority nursing action? Borderline personality disorder (BPD) is characterized by intense impulsivity and emotional dysregulation combined with unstable relationships and self-image. Individuals with BPD fear rejection and abandonment. To avoid abandonment, they use manipulation and control, often unconsciously. The manipulative behavior may be of a positive nature (eg, the use of flattery) or a negative nature (eg, distancing from the other person).

4. Reinforce unit guidelines and appropriate boundaries with the client Splitting, a primitive defense mechanism, is a prominent symptom of BPD and is the inability to hold opposing thoughts and perceiving people or events as "all good" or "all bad." Staff members should work collaboratively to prevent splitting and manipulative behaviors, as clients may attempt to turn staff against each other. The priority nursing action is to calmly reinforce unit guidelines and appropriate boundaries (Option 4).

A client with schizophrenia says to the nurse, "I was walking down the street and really enjoyed the weather, but carrots are probably my favorite vegetable. Did the ocean always look blue?" The nurse recognizes this statement as an example of which of the following? Disorganized thinking is a positive symptom of schizophrenia characterized by rambling, incoherent, or pressured speech. Clients with a disorganized thought process will often have trouble concentrating and maintaining organized and logical thoughts. It can be difficult for these clients to express their needs. Tangentiality involves transitioning from one topic to the next without getting to the point of the original idea or topic. Word salad is a mix of words and/or phrases having no meaning except to the client; this is the most extreme form of disturbed speech (eg, "Walls breathe close tomorrow with a sky that feels window.").

1. Associative looseness The nurse should be able to recognize various types of thought disturbances. Associative looseness (eg, loose associations, derailment) is a form of disorganized thinking characterized by rapid, shifting ideas with little or no connection; clients are unaware that these topics or ideas are not connected (Option 1)

The nurse is providing care to a client with posttraumatic stress disorder following a terrorist attack at the client's place of worship. The client says, "I'm just so worried all the time. I will never be safe again!" What is the priority nursing action? (Option 3) Encouraging the client to talk about the trauma is important because it helps healing; however, assessing the client's readiness to disclose the event should be done first.

1. Acknowledge the client's feelings Building a therapeutic alliance is a priority when caring for a client with PTSD. Building trust by active listening and acknowledging the client's feelings (eg, anger, sadness, guilt) of the precipitating event helps strengthen the therapeutic alliance and decreases feelings of isolation. The nurse should assess clients' readiness (ability and willingness) to discuss details of the traumatic event at their own pace without experiencing high levels of anxiety (Option 1).

Appropriate nursing interventions for clients experiencing auditory hallucinations (eg, hearing voices from imaginary friends, talking to self) and persecutory delusions (eg, suspicion of staff implanting device inside client) include:

- Providing activities (eg, music) to distract the client from internal stimuli (eg, voices) - Opening medication packages in front of the client to reduce feelings of paranoia and fear of being poisoned - Assessing the content of the delusion or hallucination to help identify homicidal or suicidal ideation (assess if voices are talking about self-harm) - Reinforcing reality by talking about real people and situations - Physical touch, especially during hallucinations or delusions, may feel threatening to the client and result in aggression. Therefore, it is not appropriate for the nurse to touch the client without warning. -It is not appropriate to discredit the client's beliefs because this does not foster trust and can worsen feelings of hostility or paranoia. The nurse should understand that the client lacks insight about the illness and that delusions persist despite rational explanations.

Acute psychosis is characteristic of many psychiatric illnesses (eg, schizophrenia, bipolar disorder) and refers to bizarre thinking that is disconnected from reality. Symptoms of psychosis include hallucinations (ie, false sensory perceptions that have no external stimuli) and delusions (ie, strong, false beliefs that are accepted by the client as real). Social withdrawal (eg, moving into a shed with the family dog) and disorganized speech are symptoms of psychiatric disorders that warrant further assessment. However, the priority is for the nurse to assess the content of hallucinations/delusions.

A client experiencing persecutory (paranoid) delusions has the false belief of being the object of others' intent to harm (eg, alien attack). Such a client may also display mistrust of others (eg, being watched by the government, asking if interview is being recorded). A client experiencing auditory hallucinations hears voices that are not real to others. The nurse should suspect that the client is experiencing auditory hallucinations when the client appears to be responding to the voices (eg, "I said I'll find them"). This client is at high risk for self- or other-directed violence and requires further assessment and intervention.

The nurse is teaching the client about newly prescribed alprazolam and sertraline. Which of the following statements by the nurse are appropriate to include in the teaching? Select all that apply. Clients with panic disorder are often treated with selective serotonin reuptake inhibitors (SSRIs) (eg, sertraline) or selective norepinephrine reuptake inhibitors (SNRIs) (eg, venlafaxine) for long-term maintenance. During the initial stages, anxiety may worsen because clients with panic disorder are quite sensitive to these medications. Therefore, benzodiazepines are frequently co prescribed in the first few weeks of treatment because they work much faster and are more efficacious.

1. "Avoid driving after taking alprazolam." -Clients should avoid driving while taking benzodiazepines because these medications can cause fatigue, drowsiness, and sedation, especially during the initiation of therapy and following dosage increases (Option 1) 2."Contact your health care provider immediately if you experience suicidal thoughts." 3."Do not abruptly stop taking alprazolam because you may experience withdrawal symptoms." Benzodiazepines must not be taken with other central nervous system depressants (eg, alcohol). However, short-acting benzodiazepines (eg, alprazolam) are helpful to treat acute symptoms.

A client wanders away from home and is found 48 hours later sleeping on a park bench. The client is brought to the emergency department by the police. The client is awake, alert, and oriented, but cannot recall their name, address, or events that occurred in the past 2 days. What is the priority nursing action? Clients experiencing dissociative amnesia have difficulty remembering autobiographical information (eg, name, address) and may present with dissociative fugue (eg, traveling to new location in a dissociative state). Dissociative disorders often originate from past trauma and can be mistaken with or caused by an underlying condition, including substance use (eg, alcohol, cannabis), neurocognitive disorders (eg, Alzheimer disease), or a traumatic brain injury. Removal from the stressful situation (ie, being away from home for 48 hours) can cause memory to return and the fugue to remit.

1. Assess vital signs Maslow's Hierarchy of Needs states physiological needs (eg, water, food, oxygen, temperature regulation) must be met before all others (eg, safety, social needs). These essential needs were deprived while the client was in a dissociative state. Therefore, the priority nursing action is to conduct a thorough physical assessment, including measuring the client's vital signs (Option 1). The nurse should complete a mental status examination as part of their assessment, but not before measuring the client's vital signs.

The nurse is caring for a client newly admitted with an acute manic episode of bipolar I disorder. The nurse identifies which food selection as the most appropriate to promote client nutrition? Bipolar disorder is a psychiatric condition characterized by cycling periods of mania/hypomania and depression. Bipolar I is characterized by the presence of a manic episode, whereas bipolar II is characterized by episodes of major depression and hypomania. Manifestations of acute mania last at least 1 week and include mood changes (eg, elevated/expansive or irritable mood), distractibility, increased energy, decreased need for sleep. In addition, the client is involved in activities (eg, hypersexuality, excessive spending, abrupt business investments) that have the potential for painful consequences.

2. Chicken sandwich, almonds, apple slices, milk Increased energy levels and distractibility can lead to unintentional neglect of personal needs (eg, hydration, nutrition, sleep, hygiene). Extreme hyperactivity without adequate nutrition and hydration can result in cardiovascular compromise. Clients should be frequently offered high-calorie, protein-rich finger foods (eg, chicken sandwich, almonds, apple slices, milk) to promote nutritional intake when they are unable to sit down and complete a traditional meal (Option 2).

The nurse makes a home visit to a client with Alzheimer disease. While reviewing the client's home care needs, the client's spouse states, "It's hard to see my spouse worsen each day. I'm not sure I can keep doing this alone anymore." Which response by the nurse is best? (Option 4) Restating client statements can be therapeutic because it shows that the nurse has analyzed what has been said. However, this response does not prompt the client to discuss potential difficulties in providing care.

3. "Tell me about the care you provide in a typical day and its challenges. Asking about the nature and requirements of providing daily care allows the caregiver to discuss the demands of providing care and helps the nurse understand stressors and unmet needs (Option 2). This type of inquiry is a therapeutic response that encourages verbalization of thoughts, feelings, and concerns. Assessment of caregiving challenges also helps to identify opportunities for assistance (eg, skills training, support groups) and community resources (eg, home health care, food/nutrition services).

For each finding below, click to specify if the finding is consistent with the disease process of opioid overdose or tricyclic antidepressant overdose. Each finding may support more than one disease process. Tricyclic antidepressants (TCAs) (eg, amitriptyline, nortriptyline) are used for treatment-resistant depression and chronic pain (eg, peripheral neuropathy, migraines). Its effects are due to inhibition of norepinephrine and serotonin reuptake. The extensive adverse and toxic effects are due to antagonism of multiple other receptor sites such as histamine and acetylcholine and include:

Opioid overdose: Altered mental status, Hypoactive bowel sounds - Acute opioid intoxication presents with respiratory depression (respirations <12/min and shallow), altered mental status, pinpoint/constricted pupils, and hypoactive bowel sounds. Heart rate can be normal or low. Fever and flushing are not present. Tricyclic Antidepressant Overdose: Heart rate 120/min, Altered mental status, Hypoactive bowel sounds, Temperature 101.4 F (38.6 C), Facial flushing and hot, dry skin, Pupils 5 mm with sluggish reaction - Cardiovascular effects - tachycardia, orthostatic hypotension, and QT prolongation. - Central nervous system effects - sedation and, in an overdose, may lead to altered mental status or seizures. - Anticholinergic effects - hyperthermia, hypoactive bowel sounds, pupillary dilation, facial flushing, urinary retention, and dry skin and mucous membranes. Decrease in anticholinergic vagal stimulation further contributes to tachycardia.

Appropriate interventions for the client with major depressive disorder who is experiencing suicidal ideation include:

- Assigning the client to a shared room near the nurses' station to reduce social isolation and allow easier access to the client. - Avoiding utensils on the client's meal tray that could be used for self-harm. - Checking on the client at frequent, irregular intervals (if not under 1-to-1 observation) to lessen predictability of staff surveillance. - Performing frequent room searches for harmful objects to ensure client safety. - Performing mouth checks after medication administration to ensure the client has swallowed medication and is not saving them for a future overdose attempt. - Encouraging the client to participate in grooming and hygiene as the client may exhibit loss of interest in daily activities, decreased energy, and lack of motivation. It is not appropriate for the nurse to document that the client is not available for a safety check when the client is using the restroom. The nurse must ensure that there is visual contact with the client during safety checks, even if the client is in the restroom, to ensure safety.

When caring for a client in a state of crisis, the nurse should assess for suicidal ideation. The nurse should consider the client's demographics, mental and physical health history, family history of suicide, previous suicide attempts, and protective factors (eg, support system, coping skills). Factors that increase the client's risk for suicide include:

- Previous attempted suicide (eg, jumping off a building) - Thoughts, intent, or plan to self-harm - History of substance use (eg, cocaine, marijuana) - Significant or sudden life loss, change, or stressor (eg, divorce) - Mental health disorder (eg, depression) - Symptoms of severe depression (eg, weight loss, difficulty concentrating, fatigue, feelings of worthlessness)

A client is receiving nasogastric tube feedings as nutritional rehabilitation for anorexia nervosa. After a weigh-in, the client learns of gaining 2 lb (0.9 kg) and says to the nurse, "See what your force-feeding has done to me? I'm fatter and uglier than ever." What is the best initial action by the nurse?

1. Acknowledge the client's distress and explore underlying feelings - Clients with AN often experience low self-esteem and impaired body image (eg, describing self as fat despite being extremely thin). Clients are often reluctant to seek treatment, and when treatment is initiated, they experience intense psychological distress. Acknowledging the client's distress and exploring fears that contribute to maladaptive eating patterns is essential for life-long recovery (Option 1).

Which of the following findings require immediate follow-up? Select all that apply.

1. Chest tightness 3. Heart palpitations 5. Shortness of breath Client findings that require immediate follow-up include signs of cardiac (eg, heart palpitations) or respiratory (eg, shortness of breath, chest tightness) distress because these may indicate possible life-threatening complications (eg, myocardial infarction) (Options 1, 3, and 5).

A client with schizophrenia is started on clozapine/clozaril. Which periodic measurements take priority in this client? Clozapine (Clozaril) is an atypical antipsychotic medication used to treat schizophrenia that has not responded to standard, more traditional treatment. Clozapine is associated with a risk for agranulocytosis (a potentially fatal blood disorder causing a dangerously low WBC count) and is therefore used only in clients with treatment-resistant schizophrenia. Hyperglycemia, dyslipidemia, and weight gain are potential side effects of clozapine therapy but are not as serious as agranulocytosis.

1. Complete blood count and absolute neutrophil count A client must have a WBC count of ≥3500/mm3 (3.5 × 109/L) and an absolute neutrophil count (ANC) of ≥2000/mm3 (2 × 109/L) before starting clozapine, so it is critical to obtain a baseline complete blood count and ANC. Because agranulocytosis is reversible if caught early, the client's WBC count and ANC must also be monitored regularly throughout the course of clozapine therapy (initially once a week) (Option 1). Clients should also contact the health care provider immediately if they develop fever or sore throat, which can indicate infection due to neutropenia.

A client recently admitted to the inpatient unit for treatment of alcohol use disorder says to the nurse, "I came here only to get away from my nagging spouse. I think my spouse should be here instead of me because I can stop drinking any time I want." The nurse recognizes that the client is exhibiting which of the following defense mechanisms?

1. Denial and projection Denial, a defense mechanism, is the refusal to accept the reality of threatening situations or painful thoughts or feelings (eg, "I don't have a drinking problem."), therefore blocking events from awareness. Denial is the most frequent defense mechanism used by clients with alcohol use disorder because such clients may be unwilling to recognize excessive and problematic patterns of alcohol consumption. Projection involves placing one's own thoughts, feelings, or impulses onto someone else (eg, spouse is the problem, not me) (Option 1).

The mental health nurse is planning care for a client newly admitted with dissociative identity disorder. Which interventions will the nurse include? Select all that apply.

1. Develop a trusting relationship with each of the alternate identities - The nurse should attempt to form trusting, therapeutic relationships with each identity to explore feelings and facilitate identity integration (Option 1). 2.Encourage the client to journal about feelings and dissociation triggers 4. Listen for expressions of self-harm from the alternate identities 5. Teach grounding techniques such as deep breathing to hinder dissociation

After removing the blankets from the client's room, the nurse should ______ and ________

1. Notify the healthcare provider 2. Initiate 1-to-1 observation This client is at high, imminent risk for suicide. The client has severe depression, suicidal ideation with a plan, and access to lethal means (eg, blankets that can be used for self-hanging). This client requires constant visual contact (ie, 1-to-1 observation) 24 hours a day to ensure safety. The nurse should also notify the health care provider to assess for underlying psychiatric disorders (eg, psychosis) that could contribute to the situation.

The nurse should prioritize interventions for _____ due to the risk of ______

1. complicated grieving 2. Self-harm The client's feelings of self-blame for the sibling's death, preoccupation with thoughts of the loss, intense emotional pain, and angry outbursts are characteristic of complicated grieving. Complicated grieving results in maladaptive thoughts (eg, hopelessness) and dysfunctional behaviors (eg, suicidal ideation). Therefore, the nurse should prioritize interventions for complicated grieving (eg, cognitive-behavioral therapy) due to the risk of self-harm.

The nurse should prioritize interventions for _____ due to the client's ______________ The nurse should prioritize interventions for suicidal behavior due to the client's thoughts of self-harm.

1. suicidal behavior 2. thoughts of self-harm This client has several predisposing factors that increase the risk for suicide, including a psychiatric disorder, previous suicide attempt, stressful life events (eg, divorce), and substance use. However, the strongest single factor predictive of suicide is the history of a prior suicide attempt (eg, jumping off a building). The nurse should anticipate implementation of suicide precautions (eg, 1-to-1 observation).

The nurse is caring for a client with severe anorexia nervosa. Which of the following findings are consistent with this diagnosis? Select all that apply.

1.BMI of 16 kg/m2 2.Fine, downy hair on the face and back 3.Has not menstruated in 3 months 4.Potassium of 3.1 mEq/L (3.1 mmol/L) - Decreased metabolic rate: severe weight loss results in hypotension, bradycardia, decreased body temperature (hypothermia), and cold intolerance Life-threatening complications, such as cardiac dysrhythmias from hypokalemia, may develop.

A nurse is admitting a child and observes multiple irregular bruises. Which action should the nurse take next? Parents should remain present during the admission process and the nurse should observe parent-child interactions for signs of abusive behavior (eg, refusal to comfort, blaming, belittling) (Option 1). Abusive parents may be hostile or uncooperative with the health care team. The nurse should also assess for inconsistencies between the parents' report and the actual findings.

2. Continue with a detailed interview and physical examination A nurse who suspects child abuse should conduct a detailed interview and physical examination to identify potential indicators of abuse (Option 2). In addition to obvious injuries, abused children may show extremes in behavior, including being overly shy, fearful, or even unusually affectionate.

The nurse is assessing a client with a history of alcohol use disorder who had an emergency appendectomy 3 days ago. Which of the following findings would indicate that the client is experiencing delirium tremens? Select all that apply.

2. Diaphoresis 3. Hallucinations 5. tachycardia Alcohol withdrawal syndrome occurs after cessation of or significant reduction in alcohol consumption following consistent, long-term alcohol intake. Because alcohol is a central nervous system (CNS) depressant, abrupt cessation causes CNS hyperactivity that, if left untreated, can result in seizures and death. Delirium tremens, which occurs around 48-96 hours following the client's last drink, is characterized by agitation, hypertension, diaphoresis, hallucinations, and tachycardia (Options 2, 3, and 5). Withdrawal symptoms can be prevented with benzodiazepine administration during hospitalization.

0 The nurse is planning care for a newly admitted client with schizophrenia who is experiencing persecutory delusions. Which of the following interventions should the nurse include in the client's plan of care? Attempting to explore the meaning behind a delusion encourages the client to give more thought and attention to the delusion, and clients initially lack the judgment and insight necessary to critically examine the delusions. In addition, probing for information about the delusions may increase the client's feelings of suspicion and reinforce the client's mistrust of others.

2. Focus on the client's feelings related to the delusions Clients who experience persecutory delusions believe they are being persecuted or harmed by others (eg, spied on, cheated, poisoned), and often display fear, paranoia, and a mistrust of others. Establishing a therapeutic nurse-client relationship is essential in the treatment and recovery of clients with persecutory delusions. Assisting the client to explore feelings related to the delusions while using active listening and empathy will help develop the therapeutic nurse-client relationship and gain the client's trust (Option 2).

A client with schizophrenia has been hospitalized for 2 days and was prescribed an antipsychotic medication at admission. The client tells the nurse of hearing multiple voices all day long arguing about whether the client is a good or bad person. The client says, "Everyone tells me that the voices are not real, but they are driving me crazy." What is the best action by the nurse?

2. Provide music for the client Appropriate nursing interventions for clients experiencing auditory hallucinations (eg, hearing voices, talking to self) and persecutory delusions (eg, false belief that staff is trying to cause harm) include: - Providing activities (eg, music) to distract the client from internal stimuli (eg, voices) (Option 2) - Assessing the content of the delusion or hallucination to help identify homicidal or suicidal ideation - Reinforcing reality by talking about real people and situations

A child with a high level of school absenteeism is diagnosed with separation anxiety disorder. The school nurse should instruct the child's parent to take what action?

3. Have the child attend school again, starting with a few hours each day Establishing a trusting relationship with the child helps the child discuss fears of separation and be more open to change. The nurse should encourage the parents to gradually expose the child to the school environment (eg, half-days) to decrease the child's sensitization to the classroom setting (eg, systemic desensitization). Parents should provide positive reinforcement (eg, praise) to promote repetition of desired behavior (Option 3

A client with newly diagnosed end-stage renal disease was transferred to the behavioral health unit after being found in the bathroom attempting suicide using hospital gown ties. What action by the nurse is priority at this time?

3. Initiate continuous one-to-one observation A client who has attempted suicide is at significantly high risk for another attempt. The priority nursing action is to create an environment of safety by initiating one-to-one observation until the client is stabilized. Continuous observation allows for a trained staff member to monitor and document the client's mood, behavior, and location, all of which will greatly reduce the risk for self-harm behaviors. Closely observing the client will also convey a sense of empathy and concern and allow the client to express feelings (Option 3)

The nurse is admitting a client from the emergency department at 2100. The client has acute alcohol intoxication, confusion, and a diabetic toe ulcer and last consumed alcohol at approximately 1830. Which of the following actions would be a priority for the nurse to take? ) Alcohol withdrawal syndrome generally begins within 6-8 hours after the last drink and peaks at 24-72 hours. The client last consumed alcohol <3 hours ago, so monitoring for alcohol withdrawal syndrome is not yet a priority. - hallucinations/seizures 12-48 hours - delirium tremens - 48+

3. Monitor the client's capillary blood glucose levels during the night Alcohol is a toxin that causes central nervous system depression. Acute alcohol intoxication can cause confusion, coordination impairment, drowsiness, slurred speech, mood swings, and uninhibited actions. Alcohol can also cause hypoglycemia, especially in clients with diabetes mellitus. Although the client is intoxicated, determining whether the confusion is caused by alcohol or hypoglycemia or both is difficult. Monitoring blood glucose levels during the night is a priority to assess for hypoglycemia, which would require immediate intervention (Option 3).

The client returns to the mental health clinic for a one-month follow-up visit. Which client statement would indicate that the client requires additional therapy to appropriately cope with the panic disorder?

4. "Taking the bus to work has been a trigger for me so my boss is letting me work from home." The client is demonstrating avoidance symptoms (eg, avoiding public transportation) in which escape in the event of a panic attack may be difficult. This can indicate agoraphobia, which suggests the client is not improving and requires further assessment (Option 4).

A young client is diagnosed with major depressive disorder. Three weeks prior, the client's fiancé broke off their engagement, claiming the client was "too fat and ugly." During a one-on-one interaction with the nurse, the client says, "My fiancé is really wonderful and is not to blame for calling off the engagement. I look awful and I'm not much good for anything." What is the best response by the nurse?

4. "Tell me how you felt when your fiancé broke up with you." Nursing interventions for a depressed client who expresses feelings of worthlessness and guilt and has a distorted sense of reality include listening attentively, encouraging the client to verbalize feelings about what has happened, and helping the client view the situation in a more realistic way.

The nurse on the mental health unit is leading a group session. Shortly after the session begins, a newly admitted client with schizophrenia stands and starts to leave the room. Which of the following actions should the nurse take? Pressuring the client to attend group sessions is not appropriate; participation should be encouraged based on the client's comfort level.

4. Remain silent and allow the client to leave the room with another staff member Assessing the client's readiness to engage with others and avoiding forcing the client to interact if unready. Assigning a staff member (eg, mental health technician) to the client ensures safety while enabling the client to take a break from the group session as needed (Option 4). - Gaining the client's trust gradually by making brief, frequent contact and showing acceptance and empathy. - Praising progress toward increased interactions with others.

The nurse is caring for the client 4 days after admission. For each finding below, click to specify if the finding indicates that the client's status is improving or concerning.

Improving: Client ate 80% of meals and took a shower today, Client is seen joining group activities in the day room. Concerning: Client is seen handing their watch and photo album to another client, Client states, "I feel more energetic today than I have in many months.", Client reports depression 0/10 and states, "I feel a lot better. I think I know what I need to do now." - During the early phase of therapy with antidepressants (eg, selective serotonin reuptake inhibitors [escitalopram]), the risk of suicide may increase because clients can become more energized as the depression lifts, enabling them to carry out previous suicide plans. The nurse should find concerning the client's statements about feeling more energized and "knowing what to do now," which can indicate that the client has determined a plan for suicide and is at peace knowing the plan

Which of the following conditions should the nurse suspect? Select all that apply.

Major depressive disorder (MDD) is characterized by a persistent depression in mood (eg, sadness, social withdrawal, thoughts of self-harm) that interferes with daily life. MDD is a significant risk factor for suicide. Substance use disorder is the recurrent use of alcohol and/or recreational drugs that results in interpersonal dysfunction, impaired control, and physical effects (eg, withdrawal).

The nurse is caring for the client 7 days after admission. For each of the statements made by the client, click to specify whether the statement indicates that the client's status has improved or not improved. Educational objective:Signs and symptoms of improvement in clients with posttraumatic stress disorder include improved sleep, willingness to talk about nightmares, and controlling negative emotions. These demonstrate improved ability to manage anxiety and cope with stressors.

Not improved: "I am thinking about selling my car and taking the bus instead." Improved: "I woke up only once last night.""I want to talk about the nightmare I had.""I have been journaling my stressors and emotional reactions to those.""Sometimes I still get upset by small issues, but I control my feelings better now."

After administering a prescribed IV fluid bolus, the nurse should prioritize administration of ____ to ____- The priority intervention for tricyclic antidepressant overdose is administration of IV fluids and IV sodium bicarbonate. Sodium bicarbonate narrows the widened QRS complex and reduces the risk of fatal arrhythmias.

The priority intervention for tricyclic antidepressant (TCA) overdose management is administration of IV fluids and sodium bicarbonate IV. Sodium bicarbonate raises the blood pH, which neutralizes toxic levels of TCAs by reducing the drug's receptor-binding ability. Sodium bicarbonate also increases the extracellular sodium concentration, which helps overcome the sodium channel blockade induced by TCAs. These effects narrow the widened QRS complex and reduce the risk of life-threatening arrhythmias.

The clinic nurse speaks with the spouse of a client being treated for alcohol use disorder. Which statements by the spouse indicate codependence? Select all that appl

1. "I cannot imagine anyone else caring for my spouse." 3. "I try to keep the children from being too loud so my spouse can sleep in on the weekdays."4." 4. My spouse is typically a social drinker. I don't see the problem with drinking a little more than usual." 5."When my spouse doesn't come home until late in the evening, I encourage my spouse to call in sick and rest." Codependent individuals focus all their attention on others at the expense of their own sense of self. Codependent spouses, friends, and family members can keep the client from focusing on treatment; this behavior is counterproductive to both themselves and the client. Codependency can look different in each family dynamic. However, it is almost always coupled with enabling the client and failure to recognize that the client has a problem (Options 1, 3, 4, and 5).

The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. The client says in a trembling voice, "There's a bad man standing over there in the corner of my room." What is the best response by the nurse?

1. "I know you are frightened, but I do not see a man in your room." When a client is experiencing hallucinations, the nurse needs to reinforce reality and acknowledge how the client may be feeling (Option 1). The nurse can point out their own perceptions without denying the client's experience. It is nontherapeutic to argue with or challenge the client about the hallucination, saying, for example, "How could a man get into your room? This is a locked hospital unit. "I don't see anything, but I understand that what you are seeing may be very upsetting to you." "I understand that you are worried about the voices you are hearing. They are a part of your disease and not real." "I know the voices seem real to you and may be scary. I do not hear the voices."

Which 4 client findings require immediate follow-up by the nurse? Select all that apply. The client was brought to the emergency department by the parents after taking an unknown number of tablets 3 hours ago. The client was found with empty prescription bottles found on the floor nearby. The client is lethargic, mumbling incoherently, arouses with repeated physical stimulation, and is oriented to person only. Face is flushed and skin is hot and dry. Pupils equal at 5 mm and react sluggishly to light. Breath sounds clear bilaterally. S1 and S2 are heard. Peripheral pulses 2+. Abdomen is soft with hypoactive bowel sounds in all 4 quadrants. Suprapubic fullness palpated.

1. Blood pressure 3. Heart rate 4. Mental Status 6. Suprapubic fullness - Suprapubic fullness, along with the other anticholinergic findings (dry and warm skin, enlarged pupils, and hypoactive bowel sounds), suggests urinary retention. This needs to be relieved immediately because this can cause severe pain and hydronephrosis (ie, excess fluid buildup in the kidneys). Hydronephrosis increases the risk for urinary tract infection and pressure-induced acute kidney injury (Option 6). Client findings that require immediate follow-up by the nurse include indicators of cardiac and central nervous system toxicity such as alterations in temperature, heart rate, blood pressure, and mental status. Acute urinary retention should always be relieved as quickly as possible.

Which of the following symptoms are consistent with schizophrenia? Select all that apply. Schizophrenia is a mental health disorder characterized by periods of psychosis that can cause significant cognitive, social, and functional deterioration (eg, job loss). Clients with schizophrenia can experience positive or negative symptoms during the active phase of the disease, and these can be exacerbated by stress, medical comorbidities, chronic substance use, or medication noncompliance. Positive symptoms are perceptions, thoughts, or behaviors that should not be present (eg, delusions, hallucinations, paranoid delusions, neologisms, and echolalia). Negative symptoms are expressions or behaviors that should be present but are now absent or decreased (flat affect, anhedonia, and anergia.

1. Disorganized speech - , loosening of associations, nonsensical words 2.Flat affect - monotone voice, little emotion 3.Laughing for no apparent reason - Responding to internal stimuli (e 4.Loss of interest in pleasurable activities -or inability to experience pleasure in life (ie, anhedonia) 5.Self-care deficit - disheveled appearance) - Absence of motivation to initiate or complete tasks (ie, avolition) Inappropriate behavior (eg, unpredictable agitation, bizarre behaviors)

The nurse is caring for a client with mild to moderate dementia in a residential facility. The client is exhibiting sundowning behavior and is found wandering throughout the hallway in the middle of the night. When communicating with the client, what statement by the nurse is most appropriate? Sundowning (sundown syndrome) is characterized by acute behavioral disturbances experienced by clients with dementia. Sundowning typically occurs in the late afternoon or evening and is linked to a disruption in circadian rhythm. These clients often remain awake during the night and experience increased confusion, wandering, and/or aggression. Risk factors include decreased exposure to light and a disturbed sleep pattern.

3. "You are in the residential home. Let us go back to your room together." When caring for clients experiencing sundowning, the nurse should first listen to their concerns to identify their source of fear or agitation and reorient them to the present time and environment (eg, "You are in the residential home. Let us go back to your room together.") (Option 3).

The nurse provides teaching for a client newly prescribed disulfiram for alcohol abstinence. Which information is the priority for the nurse to include? Disulfiram (Antabuse) is a form of aversion therapy that promotes abstinence from alcohol. If the client consumes alcohol while taking disulfiram, unpleasant side effects (eg, headache, intense nausea/vomiting, flushed skin, sweating, dyspnea, confusion, tachycardia, hypotension) can occur. If large amounts are consumed, the reaction can be fatal. Disulfiram therapy does not cure alcoholism; the client should continue seeing a therapist (Options 1 and 2).

3. List of everyday items containing hidden alcohol Due to the hazards of treatment, clients are carefully selected for disulfiram therapy, and informed consent is often required. It is a priority for the nurse to educate the client about the hazards of drinking alcohol and about sources of hidden alcohol (Option 3). Teaching includes: - Avoid hidden alcohol in:liquid cold and cough medication, saftershave lotions, colognes, and mouthwashes, foods such as sauces, vinegars, and flavor extracts - Abstain from alcohol for 2 weeks after the last dose as the disulfiram reaction could still occur - Wear a bracelet alerting others of being on disulfiram therapy (Option 4)

A client is in restraints after punching another client on the mental health unit. The client states, "I'm Houdini. I can get out of anything. There could be trouble now." What is the best response by the nurse? Mechanical restraints may be necessary only as a last resort for clients at high risk for violence. Clients placed in restraints must be continuously observed per facility protocol (ie, one-to-one observation every 15 min) by a trained staff member. The nurse should monitor the client for needed hydration, elimination, and positioning; ensure that circulation is not compromised; and determine readiness for removal of restraints

4. "What kind of trouble are you thinking about?" For clients with an increased risk for violence (eg, prior assault), the priority nursing action is to explore potentially threatening statements (eg, "There could be trouble now.") and maintain an environment of safety (eg, rechecking the restraints). Seeking clarification of the client's statement will help the nurse determine the next steps in providing care (Option 4).

A client with a history of major depressive disorder with psychotic features was rescued before jumping off a dam. The client is pacing, picking at the arms, and repeatedly mumbling, "I have to die. You cannot stop me." When the health care provider recommends electroconvulsive therapy (ECT) as the initial treatment, the client's spouse says to the nurse, "I can't allow such a cruel treatment. Why can't they just give my spouse medication?" Which is the best response by the nurse? Due to the severity of this client's clinical presentation, ECT would be the appropriate initial treatment. The client's depression has psychotic features and the suicide attempt used a highly lethal method. The client continues to be highly suicidal as evidenced by behavior and thought content. ECT can be highly effective in helping severe depression, when clients pose a severe threat to themselves and it is not safe to wait until medications take effect. ECT is also used in clients who have not responded to medication or cannot tolerate side effects. The usual course of acute therapy is 6-12 ECT treatments performed 2-3 times a week. Response to ECT can be dramatic and life-saving. Maintenance therapy (trea

4. "Your spouse is very ill and ECT might be the best treatment at this time. What are your concerns about ECT?" - The best response to a client or family member who expresses doubts about ECT is to ask about their concerns. Responses such as, "Tell me about your concerns," or "What do you understand about ECT?" allow the nurse to assess their knowledge and implement educational interventions to address any misinformation or knowledge gaps.

The nurse in the mental health unit is reviewing the social histories of assigned clients. Which of the following information in a client's history would be consistent with antisocial personality disorder? paranoid personality disorder = underlying distrust of others and their actions. borderline personality disorder = Suicidal ideation and/or attempt exaggerated sense of self-importance and the desire for admiration from others = narcissistic personality disorder.

4. Client was fired from a job for repeated sexual harassment accusations and stealing office electronics Antisocial personality disorder (ASPD) is characterized by antagonistic and uninhibited behaviors, including unlawful or inappropriate actions (eg, sexual harassment), deceitfulness, impulsivity, lack of empathy, and manipulation of others for personal gain (eg, stealing, blackmailing) (Option 4). Clients with ASPD are often quick to anger, and when they do not get their way, they become furious, vindictive, and aggressive.

A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking, hyperventilating, and having heart palpitations. What is the priority nursing action?

4. Remain in the room with the client This client is experiencing symptoms of a panic attack and should not be left alone. The priority nursing action is to stay with the client to ensure the client's safety and offer support (Option 4). Additional nursing actions while the client is experiencing panic symptoms include: - Maintaining a calm, matter-of-fact approach - Speaking calmly and using simple, clear words and phrases when providing information on emergency department procedures - Placing the client in a room with as few stimuli as possible - Administering a prescribed anxiolytic medication (eg, benzodiazepine) - Having the client take slow, deep breaths if hyperventilation is a concern

DSM-5 Personality Disorders

Cluster A = Odd or Eccentric Paranoid, schizoid, and schizotypal personality disorders Cluster B = Dramatic or Erratic Antisocial, borderline, histrionic, and narcissistic personality disorders Cluster C = Anxious or Fearful Avoidant, dependent, and obsessive-compulsive personality disorders

For each potential intervention, click to specify if the intervention is indicated or contraindicated for the care of the client.

Indicated: Encourage the use of positive self-talk, Ask the client about any recent life stressors, Teach the client to recognize physical symptoms of anxiety, Teach abdominal breathing exercises to use at the onset of anxiety Contraindicated: Encourage the client to spend time alone when feeling anxious Interventions for clients with panic disorder include asking about any recent life stressors, teaching abdominal breathing exercises to use at the onset of anxiety, teaching the client to recognize physical manifestations of anxiety, and encouraging the use of positive self-talk. Clients should refrain from being alone in case the anxiety escalates into a panic attack.

The nurse recognizes that the client is at highest risk for developing ______ as evidenced by _______ Symptoms of thyroid storm (eg, hyperthermia, agitation, delirium) are typically severe, prominent, and require prompt intervention. The client is exhibiting no cardinal symptoms of thyroid storm, and the client's weight loss and loss of appetite are likely related to anxiety or comorbid depression.

1. Agoraphobia 2. Fear of future attacks Clients who have panic attacks may develop agoraphobia (ie, fear of leaving the house or being in public) due to the anxiety and fear of having future attacks in situations that may be embarrassing or incapacitating. Therefore, the nurse recognizes that the client is at highest risk for developing agoraphobia as evidenced by fear of future attacks

Which of the following actions should the nurse take? Select all that apply. Electroencephalography, a diagnostic procedure used to diagnose seizures, evaluates the presence of abnormal electrical discharges in the brain. The client is not experiences

1. Insert a peripheral venous access device 2.Obtain supplies for an indwelling urinary catheter - TCAs cause urinary retention and assessment findings indicate need for catheterization (Option 2) 4. Request a prescription for a 12-lead ECG 5.Request a prescription for IV fluids - correct low blood pressures

Complete the following sentence/sentences by choosing from the list/lists of options. During the acute phase of a panic attack, the nurse should_______ and ______

1. Stay with the client 2. Reassure that the client is in a safe place A panic attack is a recurrent, usually brief (eg, 10- to 30-minute) episode in which a client suddenly experiences intense anxiety, fear, and physiologic discomfort. Characteristics of a panic attack include palpitations, a feeling of impending doom, chest pain, and breathing difficulties. When a client is having an acute panic attack, the nurse should stay with the client and reassure that the client is in a safe place. These attacks can be extremely frightening to the client, but the nurse can provide reassurance of safety.

Treatment for clients with schizophrenia includes antipsychotic medication (eg, aripiprazole) and cognitive therapy to promote client safety, minimize symptoms (eg, hallucinations), and improve quality of life. Signs of improvement include:

- Socialization - The client was initially experiencing asociality (ie, decreased motivation to socialize), indicated by social withdrawal. However, the client now appears to be comfortable participating in group activities (eg, playing board games with peers). - Initiation of self-care activities - The client initially appeared disheveled, indicating a self-care deficit. The client now has increased energy and motivation to improve hygiene (eg, asking technician for hygiene supplies). = Gain of insight - The client was initially experiencing anosognosia (eg, unawareness of illness), indicated by the client stating, "I don't have any mental illness." However, the client is now able to understand and accept that the voices are part of the illness and are not real.

The nurse is caring for a client who has been hospitalized for major depressive disorder. When the nurse reminds the client that breakfast will be served in the dining room in 20 minutes, the client says, "I'm not hungry and I don't feel like doing anything." What is the best response by the nurse? "It is okay. You can join us when you are ready. Take your time." This response is non-therapeutic; the client needs assistance with ADLs.

1. "I will help you get ready, then we can walk to the dining room together." The client needs direction and structure in performing activities of daily living (ADLs); waiting for the client to feel more energetic and initiate activity and interaction on one's own is not helpful. Assisting the client with ADLs helps convey a sense of caring, provides an opportunity for interaction with the nurse, and helps raise the client's self-esteem (Option 1).

The nurse is planning care for a client with schizophrenia. The client is observed sitting in the day room watching television but does not participate in social interaction with others. What is the most appropriate activity for the client?

1. A board game with a staff member When caring for clients with schizophrenia who are struggling with social interactions, the nurse should develop a therapeutic relationship to promote trust by providing one-on-one interaction (eg, playing a board game with the client); this nonthreatening approach helps the client develop and practice basic social skills. Once the client feels comfortable, the nurse can encourage participation in activities that require increased interaction with others (Option 1).

The nurse in a psychiatric clinic is evaluating the client's response to treatment for somatic symptom disorder with cardiac manifestations. Which client statement indicates a need for further treatment?

1. "I am looking for another heart specialist to evaluate my symptoms." Somatic symptom disorder (SSD) occurs when psychological stresses manifest as physical symptoms of illness without physiological cause. Treatment has been effective if the client with SSD is able to identify alternate support systems for stress, identify perceived benefits of behaviors, employ stress management strategies, and verbalize factors associated with symptoms.

The nurse is assessing a 77-year-old client who was weaned from mechanical ventilation yesterday. The client was alert and oriented for 24 hours but is now disoriented and has difficulty focusing, short-term memory loss, and increasing lethargy. Which of the following conditions is the client most likely experiencing? Delirium is characterized by a fluctuating course of impaired cognition that can develop acutely during hospitalization or intoxication/withdrawal states. Common causes of delirium include acute medical illness (eg, condition requiring mechanical ventilation), infection (eg, cystitis, pneumonia), adverse effects of medications, dehydration, and electrolyte or metabolic disturbances. Amnesia causes short- and long-term memory loss. It can be intentionally induced by medications or may occur as a result of trauma or underlying physical/psychological disease processes.

2. Delirium

Which action should the nurse perform first? However, the nurse must first ensure the safety of other clients. (Option 4) Restraints should be used as a last resort when attempting to deescalate a client experiencing acute psychosis. The nurse should first implement other deescalation interventions (eg, medication, distraction) and reserve restraints for clients who are violent and pose a threat to others. This should occur after redirecting others away from the area.

2. Direct other clients away from the area Schizophrenia is commonly accompanied by delusions (eg, "You are all trying to poison me") that cause the client to become paranoid, fearful, and agitated. Agitation in clients with schizophrenia can quickly escalate to violent behavior. The nurse must recognize signs of escalating agitation (eg, pacing, yelling, clenching fists) and intervene immediately to maintain a safe environment (eg, directing others away from the area) (Option 2).

A client with moderate Alzheimer disease becomes agitated during mealtime and throws a plate of food on the floor. Which of the following responses by the nurse are appropriate? Select all that apply.

2. Distract and redirect the client by asking for help folding napkins for the following day's meals 5. Use direct eye contact and say to the client, "I can see that you are upset; this is a safe place" Acknowledgement of the client's emotions, which reduces feelings of being isolated and misunderstood (Option 5) Reassurance that the client will be kept safe from harm Distraction (eg, photographs, music, television) to divert the client's attention Redirection to simple tasks (eg, folding towels/napkins, stacking plates) (Option 2)

A client on an inpatient psychiatric unit throws a fire extinguisher toward another client during group therapy. Which of the following actions should the nurse implement first? 3) Verbal confrontation and discussion of the event should be avoided until the client's aggression has subsided, as confrontation may exacerbate violent behavior.

2. Escort the other individuals away from the area . In moments of escalating aggressive behavior, the priority is to maintain safety for the client displaying aggression and for other individuals in the vicinity who are at risk for injury. Therefore, the nurse's initial action should be to escort the other individuals in imminent threat of injury away from the area of disturbance (Option 2).

A 10-year-old client with autism spectrum disorder is hospitalized for a diagnostic workup. What is the most appropriate nursing action?

2. Giving the client a schedule of daily activities A structured routine and consistency during hospitalization are critical in the care of clients with autism spectrum disorder (ASD). The nurse should talk with the parent and/or caregiver to determine the client's usual patterns and habits for a typical day at home, including mealtimes, bath time, and play time. In the unfamiliar and often unpredictable environment of the acute care setting, a schedule of activities can decrease anxiety and help the client with ASD anticipate what will happen next. (Option 2)

The nurse is caring for a new mother whose newborn has been diagnosed with Down syndrome. The client says to the nurse, "I'm so worried. My husband is so devastated that he won't even look at the baby." What is the best response by the nurse? Supportive counseling is usually beneficial to new parents of children with disabilities. The nurse can refer clients to family support groups or even make the initial phone call for them. However, the nurse should first encourage the parents to express how they are feeling.

2. "How are you feeling about your baby? When helping the family cope with the crisis, the nurse needs to keep the lines of communication open and offer support. The nurse should use open-ended therapeutic communication techniques that encourage the family members to verbalize what they are feeling or experiencing (Option 2). The nurse should avoid asking "why" questions when attempting to gain more information because it can be accusatory and nontherapeutic.

The nurse is evaluating the plan of care for a client diagnosed with social anxiety disorder who has a fear of eating and drinking in public. Which of the following client statements demonstrate an improvement in coping? Select all that apply. Social anxiety disorder (ie, social phobia) is characterized as intense anxiety or fear when exposed to a public or social situation (eg, public speaking, eating or drinking in front of others). Clients who have social anxiety disorder tend to avoid participating in social situations because of the heightened anxiety and insecurity they experience. Treatment of social phobias may include medication (eg, selective serotonin reuptake inhibitors, benzodiazepines) and psychotherapy (eg, cognitive-behavioral therapy, systematic desensitization) to assist in developing effective coping strategies. As part of systematic desensitization, the client is gradually exposed to the phobic trigger, which in turn decreases anxiety.

2. "I sat in the pizza shop and drank a cola while watching people eat and then bought a slice to go." 3. "I started having lunch with my coworkers even though I still become very anxious eating in public." 5. "I went to a coffee house with my boss and focused on an upcoming project while drinking a latte." Effective coping is demonstrated by experiencing increased comfort when exposed to the phobia, developing insight and verbalizing feelings about the phobia, and distracting oneself during the phobic situation.

A client with Alzheimer disease is admitted to the hospital. The client's adult child says to the nurse, "I really want to continue caring for my mother at home, but she has become agitated and restless at night. I am awake most of the night, feel exhausted, and do not know what to do." What is the best response by the nurse? Any medication used for sleep can cause the development of delirium in older adult clients with dementia, and antipsychotic medications are used especially cautiously due to the high risk of a cardiovascular event. Keeping a client with Alzheimer disease awake during the day is a behavioral strategy that may reduce the risk of sundowning (increased confusion and agitation in the evenings). However, this response does not address the caregiver's stress and exhaustion.

2. "Our social worker can discuss supportive options with you." This caregiver is experiencing caregiver role strain, which refers to high levels of stress and exhaustion related to caring for the client. Without help, the caregiver could easily experience burnout. A social worker can provide information on resources and services for assistance and support; these include adult day programs, in-home assistance, visiting nurse services, and home-delivered meals (Option 2). The social worker can also provide the names of agencies that seek the support of others in similar situations.

The clinic nurse reviews telephone messages left by 4 clients. Which client is the priority to call back first? A spouse calling about a suicidal client is not the first priority; the client is not alone, and the spouse can call others for help (eg, police, suicide hotline) if necessary while awaiting the nurse's return call. This should be the second returned call.

2. Client with schizophrenia hearing voices advising to harm a neighbor Command hallucinations are a specific type of auditory hallucination, during which voices instruct the client to perform specific actions, often demanding harm to the client or others. Clients who are alone and experiencing command hallucinations that are homicidal or suicidal in nature require immediate intervention to ensure the safety of themselves and others (Option 2).

The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors? Histrionic personality disorder is characterized by persistent attention-seeking behavior and exaggerated emotionality. The client with this disorder demands immediate gratification and has little tolerance for frustration.

2. Likes to be the center of attention, exaggerated emotional expression, little tolerance for frustration The nurse should recognize the following characteristics associated with histrionic personality disorder: - Self-dramatizing, exaggerated or shallow emotional expression - Attention-seeking, needs to be the center of attention - Overly friendly and seductive, attempts to keep others engaged - Demands immediate gratification and has little tolerance for frustration

The nurse is speaking with the spouse of a client following a family discussion with the health care provider about the client's terminal condition and eligibility for hospice care. The spouse states, "I don't think I can make this decision right now. What would you do?" How should the nurse respond? I find it helpful to investigate the options. I will get you a pamphlet about hospice services.Providing information is an appropriate response when that is what the client is seeking. However, there is no indication that the spouse seeking advice requires additional information, and this response does not promote further communication.

3. "These decisions are challenging. Tell me your spouse's beliefs about end-of-life. When discussing decisions related to client care, the nurse should facilitate exploration of the client's emotions, values, and beliefs, rather than offer personal opinions. Nurses can promote self-exploration by using open-ended questions and guiding phrases (Option 3).

The nurse is caring for a client experiencing acute psychosis after ingesting recreational drugs. The caregiver asks the nurse if the client will develop schizophrenia. Which response by the nurse is appropriate?

3. "We can't predict if your child will develop schizophrenia. Close observation is required to determine the cause of psychosis." Recreational drugs cause an imbalance of neurotransmitters (eg, glutamate, dopamine) and can lead to an acute psychotic episode. When caring for a client who is having an acute psychotic episode, the nurse should prioritize client safety (eg, close observation) and address caregiver concerns with information (eg, "We can't predict if your child will develop schizophrenia."

An elderly client at the end of life is visited by family members. One begins to cry and asks the nurse, "Will you please stay for a few minutes?" The nurse has other clients to care for as well. Which statement by the nurse is the most helpful?

3. "I can stay and sit with you if you would like." During the end-of-life process the client's family members may be frightened, sad, confused, or concerned, and may ask staff questions about belief systems or the death process. Sometimes clients or family members simply want the nurse to sit with them and provide reassurance that their loved ones are worthy of time and attention. The most therapeutic response by the nurse is to sit with the client and/or family for at least a few minutes.

A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which statement by the nurse promotes a therapeutic relationship?

3. "Many people with cancer experience fear of dying; tell me about your concerns. "Tell me about your life. What are your hopes and goals for the future?

A recently widowed client becomes tearful at a routine clinic visit and states, "I just can't get over my spouse's death." Which of the following responses by the nurse are appropriate? Select all that apply. Clients expressing strong emotions may need time to collect themselves before continuing a discussion. However, leaving the room when a client's emotions are heightened may imply that the client's expression is inappropriate or unacceptable. The nurse should remain with the client and may use therapeutic silence or touch to show support.

4. "This is a difficult time. Tell me about how you have been coping." 5."What are your thoughts about attending a grief support group?" Reflection (eg, acknowledging client statements) and using open-ended questions or statements assist the client in exploring emotions and allow for expression of needs (Option 4). Nurses may also suggest strategies and share resources (eg, support group) to facilitate the client's grieving process (Option 5).

For each finding below, click to specify if the finding is consistent with the disease process of hyperthyroidism, myocardial infarction, or panic disorder. Each finding may support more than one disease process.

Hyperthyroidism: diaphoresis, trembling hands, heart palpitations, shortness of breath -weight loss despite increased appetite, diarrhea, Myocardial infarction: diaphoresis, heart palpitations, shortness of breath - chest pain Panic disorder: diaphoresis, trembling hands, heart palpitations, shortness of breath - chest pain, fear of dying

For each potential intervention, click to specify if the potential intervention is appropriate or not appropriate for the care of the client.

Not Appropriate: Provide the client privacy during flashbacks, Avoid discussion of the traumatic event when speaking to the client -It is not appropriate to ensure privacy during flashbacks. The nurse should remain with the client to offer reassurance of safety to calm anxiety. - It is not appropriate for the nurse to avoid discussion of the traumatic event. Debriefing is the first step toward resolution of PTSD. Appropriate: Help the client identify available support systems, Directly ask if the client is having thoughts of self-harm, Assess the client's ability to perform activities of daily living, Teach the client to use progressive muscle relaxation for anxiety

The nurse in the outpatient treatment facility evaluates the plan of care for a client with alcohol use disorder. Which of the following client statements indicate positive progress toward recovery? Select all that apply. 2. "I am in control now; I drink only on special occasions.": This statement represents denial, a common maladaptive defense mechanism in which substance misuse or addiction is minimized and/or clients deny having a problem with substance use.

1. "Drinking led to my divorce and the loss of my children." - Expressing accountability for previous behavior, including how abusing alcohol has impacted personal life (Option 1) 4. "My focus is now on fitness training and going back to college." 5. "When cravings occur, I call my Alcoholics Anonymous sponsor."

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Serotonin syndrome (ie, serotonin toxicity) is a life-threatening condition caused by excess serotonin in the central nervous system. Tramadol is an analgesic medication with serotonergic activity that can lead to serotonin syndrome when taken with a selective serotonin reuptake inhibitor (eg, sertraline).

Potential Conditions: Serotonin Syndrome Actions to Take: Discontinue sertraline, Administer a benzodiazepine Parameters to monitor: Clonus, Temperature Clinical manifestations include mental status changes (eg, anxiety, restlessness, agitation), autonomic dysregulation (eg, diaphoresis, tachycardia, hypertension, hyperthermia), and neuromuscular hyperactivity. Treatment involves discontinuing all serotonergic agents (eg, sertraline, tramadol) and administering a benzodiazepine to improve agitation and decrease muscle contraction (eg, clonus), which reduces temperature.