UWorld review

The nurse is caring for a new mother whose infant 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 it the best response by the nurse?

"How are you feeling about your baby?"

A client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting. The nurse enters the room to remind 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's the best response by the nurse?

"I will help you get ready; then we can walk to the dining room together."

A new nurse is caring for an adolescent transgender client. What question would be appropriate when assessing the client's gender identity?

"how would you describe your gender orientation?"

A client with Alzheimer disease is admitted to the hospital for a urinary tract infection. The daughter says to the nurse, "I really want to take my mother home and continue care there. However, lately, my mother has become agitated and restless at night. I'm awake most of the night, feel exhausted, and do not know what to do." What is the best response by the nurse?

"our social worder cna discuss long-term care options with you."

A client is brought to the ER after the spouse finds the client locked in the care inside their garage with the motor running. The spouse says to the nurse, "if I hadn't come home early from work, my spouse would be dead. I can't believe this is happening." What is the best response by the nurse?

"this has been very overwhelming for you. What are you feeling right now?"

The parents of a 5-year old ask the school nurse for advice on how to tell their child about being adopted. Which developmentally appropriate thought about adoption by the child does the nurse counsel the parents to anticipate?

Feels responsible for being placed for adoption.

Delusions

Fixed false beliefs that are accepted by the client as real and cannot be changed by logic, reason, or persuasion.

A nurse performs the initial assessments for 4 assigned clients. The nurse identifies which client as being at greatest risk for the development of delirium?

80-year old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis.

Deep breathing exercises

An easy and efficient approach to help they body and mind sllow down and relax.

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 action for the client's nursing care plan?

Assign different staff members to care for the client each day.

The nurse is helping to admit a client with malnutrition related to anorexia nervosa. Which actions are appropriate in the care of this client

Assist the client in reflection on triggers of disordered eating. Determine the client's required daily intake of calories. Monitor the client's weight at the same time each day.

Histrionic personality disorder

Characterized by persistent attention-seeking behavior and exaggerated emotionality. Demands immediate gratification and has little tolerance for frustration.

Reason to place locks above or below eye level for Alzheimer clients

Clients with Alzheimer Disease lose their peripheral vision; they cannot see objects unless they are directly in front of them or they purposely move their heads.

Major Depressive Disorder

Clients with low energy, lethargy, or fatigue associate with MDD need structure and direction in performing basic ADLs, and in initiating social interaction with others.

A 12-year-old with moderate intellectual disability and an intelligent quotient of 45 is hospitalized. What will the nurse recommended as the best recreational activity for this child?

Connect-the-dots puzzle book

Client with generalized anxiety disorder is referred to outpatient mental health department cognitive behavior therapy. The CBT includes which interventions and strategies?

Desensitization to a specific stimulus or situation. Relaxation techniques. Self observation and monitoring. Teaching new coping skills and techniques to reframe thinking.

The nurse performs an initial assessment on a client with suspected post-traumatic stress disorder. Which assessments would support this diagnosis?

Difficulty concentrating, feeling detached from others, flashbacks of the traumatic event, and persistent angry, fearful mood.

PTSD

Experience 3 categories of symptoms: re-experiencing the traumatic event, avoiding reminders of the trauma, and hyper-arousal.

A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions. Which nursing interventions should the nurse include in the client's plan of care with regard to the delusional thinking?

Focus on reality and verbally reinforce it. focus on client's feelings secondary to the delusions.

Treatment for anorexia nervosa

Focus on short-term outcomes of increasing caloric intake, promoting gradual weight gain, and addressing medical conditions caused by starvation.

The nurse is educating a client in preparation for discharge from the hospital when the client breaks down crying, saying that the health care provider thinks she is crazy because he diagnosed her with a functional disorder. Which statement would be the best reply to this client?

Functional disorder is a general diagnosis for a genuine medical issue that medical science does not yet fully understand.

The school nurse is called to the classroom to assist with a 7-year-old with ADHD who is throwing books and hitting the other children. What is the best initial action for the nurse to take?

Give the child a time out in a quiet place.

Dependent Personality disorder

Have an extreme need to be taken care of by another person, cannot make decisions on their own, and have intense fear of separation and being left alone. Ability to make a decision and act on one's own indicates progress.

The clinic nurse speaks with the spouse of a client being treated for alcohol use disorder. Which statements by the spouse indicate codependency?

I try to get up early and keep the children from being too loud in the mornings. If I didn't get so stressed about my job, my spouse wouldn't drink so much. When my spouse was sick I called and rescheduled clients so my spouse could rest.

Transgender clients

Identify themselves as male or female, or as neither or both. Address clients by their preferred names and use open-ended questions that allow them to explain in their own words.

A client with moderate Alzheimer disease is started on memantine. In evaluating the effectiveness of the medication, the registered nurse should assess the client for which of the following?

Improved ability to perform activities of daily living.

Borderline Personality Disorder

In an attempt to prevent abandonment and control their environment, may flatter and cling to one staff member while making derogatory remarks about others.

Therapeutic approach to a client with OCD patient

Include pointing out the amount of time the client has spent performing an activity and redirecting the client to another activity.

the nurse plans care for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. Which client outcome will the nurse prioritize?

Increases caloric intake to gain weight.

A client with severe major depressive disorder is lying in bed and has not moved for 3 hours. The client will respond slowly to "yes" and "no" questions; otherwise, the client does not respond when spoken to. The clinical manifestations exhibited by the client are known as:

Psychomotor retardation

A child with a high level of school absenteeism has been determined to have school phobia. The school nurse should counsel the child's parent/caregiver to take which action?

Insist on school attendance immediately, starting with a few hours a day.

School phobia

Insist on school attendance, along with other supportive interventions, will help the child make a faster adjustment.

Priority nursing action with client exhibiting anxiety

Intervene in a manner that helps make the client for more at ease.

OCD

Is typically rigid and inflexible and has a need to control both internal and external experiences. Changes that is outside their control could cause significant distress.

Psychomotor retardation

Key features include decreased movement, inability or decreased ability to impaired cognitive function.

A client with a 20-yr history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband. I can't find my headband. The oil is going to leak out of the crack in my head." What is the best response by the nurse?

Let's go back to your room and look for your headband together.

Most effective strategy to prevent clients with dementia from wandering

Make modifications to secure their environment.

Bulimia nervosa

Monitor for signs of hidden binging or purging activity, particularly 1-2 hours after meals. Excessive vomiting may result in electrolyte imbalances, including hypokalmia.

PTSD patients

Often experience feelings of guild and shame; they believe they're responsible for what happened and that, somehow they could have prevented the event.

After a client with Alzheimer disease is found wandering in the middle of the street at 3:00 am and returned by police, the community health nurse teaches family members about measure to keep the client safe at home. What is the most important strategy for the nurse to include in the instruction?

Place a chain lock on the door above or below the client's eye level

A female client who was the victim of acquaintance rape 2 months ago is receiving therapy for PTSD. She says to the nurse, "It's all my fault. I should have known not to accept a drink from someone I just met in a bar." What is the best response by the nurse?

You could not have anticipated the rape. You did not deserve or ask for it.

The nurse is managing the care of a client diagnosed with chronic anxiety which behavior demonstrates to the nurse that the client possesses resilience?

Practice stress reduction techniques daily.

A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the priority nursing diagnosis?

Rick for deficient fluid volume

Any client who expresses ambivalence about being suicidal

Should be treated as a "yes." The client must be in a safe environment with hospital supervision and should not be left alone.

Memantine

Slows the progression of AD symptoms, and improvement may be seen in the client's behavior, cognitive functioning, and ability to perform activities of daily living.

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, has dyspnea, and heart palpitations. What is the priotiry nursing action?

Stay with the client. The client is experiencing symptoms of a panic attack and should not be left alone.

Autism spectrum disorder

Structure and consistency are crucial when caring for this client. Limit the number of visitors, and choices to be made.

The client with narcissistic personality disorder often behaves in grandiose and entitled ways, believes that he/she is perfect, and relies on constant reinforcement and admiration from people perceived as ideal. What is the best explanation for these clinical characteristics?

The client is attempting to maintain self esteem.

Communicating with a delusional client

The nurse must focus on the client's feelings and reinforce reality rather than argue or present evidence that the delusion is false or irrational.

Risk factors for hospital-induced delirium include

advanced age, underlying neurodegenerative disease, infections, medical illness, surgery, impaired mobility, and inadequate pain control.

Catatonic Schizophrenia

are unable to meet their basic needs for adequate fluid and food intake and are at high risk for dehydration and malnutrition.