Combo with "Evolve Psych" and 1 other
A client who is dying jokes about the situation even though the client is becoming sicker and weaker. Which is the most therapeutic response by the nurse?
"Does it help to joke about your illness?"
When talking with a client who has been receiving Paroxetine (Paxil), the nurse determines that more clarification is needed when the client says:
"I've been on the medication for 8 days now, and I don't feel any better."
During a routine yearly physical an older adult says to a nurse, "I haven't had sex lately because I can't get an erection anymore!" What should the nurse's initial response be?
"Let's discuss this concern a little more."
Which client statement supports the diagnosis of somatic delusions?
"My heart stopped beating 3 days ago, and now my lungs are rotting away."
Sildenafil (Viagra) is prescribed for a man with erectile dysfunction. A nurse teaches the client about common side effects of this drug. (Select all that apply.)
Flushing Headache Dyspepsia
The parents of a toddler with recently diagnosed moderate cognitive impairment discuss their child's possibility of future independent function. What should the nurse conclude?
Denial is being used as a defense.
A client on the psychiatric unit is undergoing a pretreatment evaluation for electroconvulsive therapy (ECT). Because of the client's profoundly depressed behavior, the nurse doubts that the client can provide informed consent. What should the nurse's initial intervention be?
Having the client verbalize her understanding and the outcomes of the procedure
A client has become increasingly depressed, and the practitioner prescribes an antidepressant. After 20 days of therapy, the client returns to the clinic. The client appears relaxed and smiles at the nurse. The most significant conclusion that the nurse can draw from this behavior is that the client:
Is responding to the antidepressant therapy
A client with a history of depression tells the nurse about planning to retire from work next year. What common dynamic about retirement should the nurse consider when interacting with this client?
It is a developmental task of significance.
An agitated, acting-out, delusional client is receiving large doses of haloperidol (Haldol), and the nurse is concerned because this drug can produce untoward side effects. Which clinical manifestations should alert the nurse to stop the drug immediately? (Select all that apply.)
Jaundice Tachycardia
A nurse understands that when a client is a member of a different ethnic community it is important to:
Offer a therapeutic regimen compatible with the lifestyle of the family
When intimate partner violence (IPV) is suspected, the nurse plays an important role as an advocate for the victim. The advocate role includes several important components. (Select all that apply.)
Planning for future safety Validating the experiences Promoting access to community services
The health care provider prescribes donepezil (Aricept) 5 mg by mouth once a day for a client exhibiting initial signs of dementia of the Alzheimer type. The client is already taking digoxin (Lanoxin) 0.125 mg in the morning and alprazolam (Xanax) 0.5 mg twice a day. What should the nurse teach the client's spouse to do?
Prefill a weekly drug box with the medications for the spouse to self-administer
A client with a diagnosis of schizophrenia is discharged from the hospital. At home the client forgets to take the medication, is unable to function, and must be rehospitalized. What medication may be prescribed that can be administered on an outpatient basis every 2 to 3 weeks?
Fluphenazine
Antipsychotic drugs can cause extrapyramidal side effects. Which responses should the nurse document as indicating pseudoparkinsonism? (Select all that apply.)
Rigidity Tremors Bradykinesia
A client with a history of chronic alcoholism is admitted to the mental health unit. What does the nurse identify as the cause of a client's use of confabulation?
Marked loss of memory
When a nurse sits next to a depressed client and begins to talk, the client responds, "I'm stupid and useless. Talk with the other people who are more important." Which response is most therapeutic?
"I want to talk with you because you are important to me."
A nurse approaches a depressed client who is sitting alone in the dayroom. What is best for the nurse to say to the client?
"I'll be sitting with you for a while today."
A 17-year-old teenager is found to have leukemia. Which statements by the teenager reflect Piaget's cognitive processes associated with adolescence? (Select all that apply.)
"I'm going to do my best to fight this awful disease." "Now I can't go to the prom because I have this stupid disease." "This illness is serious, but with treatment I think I have a chance to get better."
A nurse is caring for a client with the diagnosis of dementia. What should the nurse ask the client to best ascertain orientation to place?
"Where are you?"
A nurse determines that confrontation is an appropriate tool for use with a client. What is an example of therapeutic confrontation?
"You say you're not a good parent, but you were effective when you were talking with your son today."
A depressed client tells a nurse, "I want to die." What is the most therapeutic response by the nurse?
"You would rather not live."
A client on the psychiatric unit asks a nurse about psychiatric advance directives (PADs). What information should form the basis of the nurse's response?
A client is allowed to consent to or refuse potential psychiatric treatments if a future incapacitating mental health crisis occurs.
A nurse is working in a daycare center with clients who have cognitive impairments. What does the nurse expect of a client in the middle stages of dementia?
Able to recall events from the past
What is most important for the nurse to do when caring for a client who is in an alcohol detoxification program?
Accept the client as a worthwhile person
What is the primary reason that the nurse encourages the family of an alcoholic to become involved in the treatment program?
Alcoholism involves the entire family.
In conjunction with which classification of medication are trihexyphenidyl, biperiden (Akineton), and benztropine (Cogentin) often prescribed?
Antipsychotics Antipsychotics are used to control the extrapyramidal (parkinsonian) symptoms that often develop as a side effect of antipsychotic therapy.
A client is admitted to the psychiatric unit of the hospital with a diagnosis of conversion disorder. The client is unable to move either leg. Which finding should the nurse consider consistent with this diagnosis?
Appearing composed 침착한, 차분한
The nurse recalls that the major defense mechanism used by an individual with a phobic disorder is:
Avoidance
A nurse is caring for a client with generalized anxiety disorder. Which factor should be evaluated to determine the client's present status?
Behavior
A client describes his delusions in minute detail to the nurse. How should the nurse respond?
By changing the topic to reality-based events
A client has been prescribed chlorpromazine (Thorazine) for the management of positive symptoms of schizophrenia. When the client reports difficulty sustaining an erection, the nurse:
Consults with his provider regarding alternative medication therapies
What is the greatest difficulty for nurses caring for the severely depressed client?
Contagious quality of depression
A nurse understands that autism is a form of a pervasive developmental disorder (PDD). Which factor unique to autism differentiates it from other forms of PDD?
Early onset, before 36 months of age
A nurse recalls that language development in the autistic child resembles:
Echolalia The autistic child repeats sounds or words spoken by others.
A client is scheduled for a 6-week electroconvulsive therapy (ECT) treatment program. What intervention is important during the course of treatment?
Elimination of benzodiazepines for nighttime sedation
What is the most appropriate way for the nurse to help a severely depressed adolescent client accept the realities of daily living?
Helping the client fulfill personal hygiene needs
Which suicide method is the least lethal(치명적인)?
Ingesting pills
What defense mechanism should the nurse anticipate that a client with the diagnosis of schizophrenia, undifferentiated type, will most often exhibit?
Regression
What characteristic of anxiety is associated with a diagnosis of conversion disorder?
Relieved by the symptom
A nurse is caring for an older adult with the diagnosis of dementia. Which manifestations are expected in this client? (Select all that apply.)
Resistance to change Inability to recognize familiar objects Inability to concentrate on new activities or interests Tendency to dwell on the past and ignore the present
What is the nurse's specific responsibility when the rights of a client on a mental health unit are restricted by the use of seclusion?
Seclusion and restraints are special procedures for dealing with aggressive acting-out behavior for the protection of the client and others; clear documentation is essential when the client's rights are restricted. Informing the client's family is not necessary because the use of seclusion or restraints is included in the general consent form that is signed on admission. Pharmacological intervention should be monitored for all clients. There is not a typical form; however, documentation is required to justify the need for seclusion or the use of restraints.
At times a client's anxiety level is so high that it blocks attempts at communication and the nurse is unsure of what is being said. To clarify understanding, the nurse says, "Let's see whether we mean the same thing." What communication technique is being used by the nurse?
Seeking consensual validation
What should the nurse do when interacting with an adolescent client with the diagnosis of anorexia nervosa?
Set limits
A client who has been hospitalized with schizophrenia tells the nurse, "My heart has stopped and my veins have turned to glass!" What should the nurse conclude that the client is experiencing?
Somatic delusion
A client with a diagnosis of borderline personality disorder (BPD) has negative feelings toward the other clients on the unit and considers them all "bad." Which defense is the client using when identifying the other clients thusly?
Splitting
A client comes to a mental health center with severe anxiety, evidenced by crying, hand-wringing, and pacing. What should the first nursing intervention be?
Staying physically close to the client
A withdrawn client refuses to get out of bed and becomes upset when asked to do so. What nursing action is most therapeutic?
Staying with the client until the client calms down
During the first month in a nursing home, an older client with dementia demonstrates numerous disruptive behaviors related to disorientation and cognitive impairment. What should the nurse take into consideration when planning care?
Stressors that appear to precipitate the client's disruptive behavior
A 19 year-old, arrested for assault and robbery, has a history of truancy and prostitution but is unconcerned that her behavior has caused emotional distress to others. The diagnosis of antisocial personality disorder is made. According to psychoanalytical theory, the client's lack of remorse and repetitive behavior probably are related to an underdeveloped:
Superego Lack of remorse 후회 indicates a weak superego, the aspect of personality concerned with prohibitions.
Which client characteristic is an initial concern for the nurse when caring for a client with the diagnosis of paranoid schizophrenia?
Suspicious(의혹을 갖는, 수상쩍어 하는) feelings
A nurse is caring for a client who is addicted to opioids and who has undergone major surgery. The client is receiving methadone. What is the purpose of this medication?
Switches the user from illicit opioid use to use of a legal drug Methadone may legally be dispensed; the strength of this drug is controlled and remains constant from dose to dose, unlike illicit drugs.
A client with schizophrenia is taking benztropine (Cogentin) in conjunction with an antipsychotic. The client tells a nurse, "Sometimes I forget to take the Cogentin." What should the nurse teach the client to do if this happens again?
Take a dose as soon as possible, up to 2 hours before the next dose.
A client has been taking prescribed risperidone (Risperdal) 3 mg twice a day for the past 8 days. A friend brings the client to the outpatient clinic. The client reports tremors, shortness of breath, a fever, and sweating. What should the nurse do?
Take the client's vital signs and arrange for immediate transfer to a hospital
A client has been taking prescribed risperidone (Risperdal) 3 mg twice a day for the past 8 days. A friend brings the client to the outpatient clinic. The client reports tremors, shortness of breath, a fever, and sweating. What should the nurse do?
Take the client's vital signs and arrange for immediate transfer to a hospital These clinical manifestations signal the presence of neuroleptic malignant syndrome; the cardinal sign of this condition is a high body temperature. Therefore the nurse first should document the hyperthermia and then arrange for immediate hospitalization.
What is an initial client objective in relation to anger management?
Taking responsibility for the hostile 적대적인 behavior
An adolescent on the psychiatric unit has an angry outburst toward another client who cut in front of people standing in line to get their mail. Later the nurse conducts a one-on-one therapeutic session with the angry client. What is an appropriate short-term goal for the client to strive for?
Talking about the situation that precipitated the anger
A hyperactive 9-year-old child with a history of attention deficit-hyperactivity disorder is admitted for observation after a motor vehicle collision. On what should nursing actions be focused when the nurse is teaching about personal safety?
Talking with the child about the importance of using a seat belt
In which situation is the use of seclusion contraindicated?
The client has expressed severe suicidal thoughts. Seclusion of a person experiencing severe suicidal thoughts places the client at risk for self-harm and so would be contraindicated. When the criteria for seclusion have been met, seclusion would not be contraindicated for someone who wants to be secluded, has been voluntarily admitted, or showed minimal improvement despite being secluded before.
What is the most important information for a nurse to teach to prevent relapse in a client with a psychiatric illness?
The need to follow the prescribed medication regimen
What is the most important information for a nurse to teach to prevent relapse in a client with a psychiatric illness?
The need to follow the prescribed medication regimen Following the prescribed medication regimen is important because side effects and denial of illness may cause clients to stop taking their medications; this is a common cause of relapse or recurrence of symptoms.
A recently hired nurse is caring for several clients on a mental health unit at a local community hospital. The nurse manager is evaluating the nurse's performance. What situation indicates that the nurse-client boundaries of the recently hired nurse are appropriate?
The nurse shares with the entire treatment team vital information the client disclosed in a private session.
The practitioner prescribes valproic acid (Depakene) 750 mg daily to be administered in two divided doses. The medication is supplied as a syrup of 250 mg/5 mL. How many milliliters of solution should the nurse administer per dose? Record your answer using one decimal place. __________ mL
The nurse should administer 7.5 mL per dose
A nurse notes that a client in the detoxification unit is exhibiting early signs of alcohol withdrawal. What clinical manifestations might the nurse have noticed? (Select all that apply.)
Tremors Anorexia
What characteristic uniquely associated with psychophysiological disorders differentiates them from somatoform disorders?
Underlying pathophysiology
An older client with a diagnosis of dementia is living in a long-term care facility. The client's daughter, who lives 300 miles away, calls the unit to speak to the nurse about her upcoming visit. What should the nurse say in response to her question about the best time of day to visit?
"Around 2:30 in the afternoon is the best time to visit."
A male client with the diagnosis of a bipolar disorder, depressed episode, is found lying on the floor in his room in the psychiatric unit. He states, "I don't deserve a comfortable bed; give it to someone else." The best response response by the nurse is:
"Everyone has a bed. This one is yours."
The parents of an adolescent girl are upset about their daughter's diagnosis of anorexia nervosa and the treatment plan that has been proposed. What is the best response by the nurse when the client's parents ask to bring food in for the client?
"For now, let the staff handle her food needs."
A client with schizophrenia is experiencing auditory hallucinations. A nurse makes the following statements when interacting with this client. Place these statements in the order in which they should be made.
"Hearing voices must be frightening." "The voices you hear are part of your illness." "I don't hear any voices." "Come with me for a walk." "Let's play cards with another client in the recreation room."
A nurse moves into the working phase of a therapeutic relationship with a depressed client who has a history of suicide attempts. What question should the nurse ask the client when exploring alternative coping strategies?
"How will you manage the next time your problems start piling up?"
A client with schizophrenia reports having ongoing auditory hallucinations that he describes as "voices telling me that I'm a bad person" to the nurse. What is the best response by the nurse?
"Try to ignore the voices."
Certain questions are applicable in determining nursing negligence. (Select all that apply.)
"Was reasonable care provided?" "Was there a breach of nursing duty?" "Was there an act of omission that resulted in harm? "Except for the nurse's action, would the injury have occurred?"
A person mowing a lawn is badly disfigured by the lawnmower blade. According to Erikson's theory, which age at the time of injury will be associated with the greatest risk of long-term psychological effects?
11 years An 11-year-old child is generally in Erikson's stage of industry versus inferiority, which involves the mastery of skills; unfortunately, the child did not master the skill of lawnmowing.
A person mowing a lawn is badly disfigured by the lawnmower blade. According to Erikson's theory, which age at the time of injury will be associated with the greatest risk of long-term psychological effects?
11 years An 11-year-old child is generally in Erikson's stage of industry versus inferiority, which involves the mastery of skills; unfortunately, the child did not master the skill of lawnmowing.
A nurse in a community therapeutic recreation program is working with a client with dysthymia. The treatment plan suggests group activities when possible for this client. What is the priority rationale for this intervention?
A group can offer increased support.
The nurse is caring for a client experiencing a crisis. What role is most important for the nurse to assume when providing therapeutic crisis intervention?
Active participant
When working with a client who is in an alcohol detoxification program, it is most important for the nurse to:
Address the client's holistic needs
Oral chlordiazepoxide (Librium) 100 mg/ hr is prescribed for a client with a Clinical Institute Withdrawal Assessment (CIWA) score of 25. The client has had 300 mg in 3 hours but is still displaying acute alcohol withdrawal symptoms. What is the next nursing action?
Administering chlordiazepoxide as indicated by the client's CIWA score
How should a nurse characterize a sudden terrorist act that causes the deaths of thousands of adults and children and negatively affects their families, friends, communities, and the nation?
Adventitious An adventitious crisis is a crisis or disaster that is unplanned and accidental; its subcategories include national disasters and crimes of violence.
A nurse is caring for a client with dementia. Which clinical manifestations are expected? (Select all that apply.)
Agitation Short attention span Disordered reasoning Impaired motor activities
A client who is addicted to opioids undergoes emergency surgery. During the postoperative period the health care provider decreases the previously prescribed methadone dosage. For what clinical manifestations should the nurse monitor the client?
Agitation and attempts to escape from the hospital When the methadone dosage is reduced, a craving for opioids may occur, anxiety will increase, and the client will become agitated and may try to leave the hospital to secure drugs.
On the psychiatric unit a client has been receiving high doses of haloperidol (Haldol) for 2 weeks. The client says, "I just can't sit still, and I feel jittery(초조한)." Which side effect does the nurse suspect that the client is experiencing?
Akathisia(정좌 불능) Akathisia, a side effect of haloperidol (Haldol), develops early in therapy and is characterized by restlessness and agitation. Torticollis is characterized by a stiff neck (wry neck). Tardive dyskinesia is characterized by gross involuntary movements of the extremities, tongue, and facial muscles that develop after prolonged therapy. Pseudoparkinsonism is characterized by motor retardation, rigidity, and tremors; the reaction resembles Parkinson's syndrome but usually responds to decreasing the dose, the administration of an antidyskinetic medication, or discontinuation of the haloperidol.
A nurse is planning care for a depressed client. Which approach is most therapeutic?
Allowing the client time to complete activities
An older adult resident of a nursing home who has the diagnosis of dementia of the Alzheimer type, frequently talks about the good old days at the ranch. What is the most appropriate action by the nurse?
Allowing the resident to reminisce about the past and listening with interest
A nurse is caring for a client who has been hospitalized for alcohol withdrawal. The client decides to attend an Alcoholics Anonymous meeting. What is a basic principle of this group?
Amends must be made to each person who has been harmed. The eighth step of the 12 steps of Alcoholics Anonymous (AA) is "Made a list of all persons we had harmed, and became willing to make amends to them all."
What are the "four A's" for which nurses should evaluate clients with suspected Alzheimer disease?
Amnesia, apraxia(운동 불능), agnosia(인지불능증), aphasia(연하 불능)
In conjunction with which classification of medication are trihexyphenidyl, biperiden (Akineton), and benztropine (Cogentin) often prescribed?
Antipsychotics Antipsychotics are used to control the extrapyramidal (parkinsonian) symptoms that often develop as a side effect of antipsychotic therapy. There is no documented use of anxiolytics with antianxiety agents because they do not have extrapyramidal side effects. Barbiturates do not have extrapyramidal side effects that respond to these drugs. Antiparkinsonian drugs usually are not prescribed in conjunction with antidepressants because antidepressants do not cause parkinsonian symptoms.
A nurse recalls that in a conversion disorder, pseudoneurological symptoms such as paralysis or blindness:
Are generally necessary for the client to cope with a stressful situation
An 8-year-old child is found to have oppositional defiant disorder. What behavior noted by the nurse supports this diagnosis?
Argues with adults
An 8-year-old child is found to have oppositional defiant disorder. What behavior noted by the nurse supports this diagnosis?
Argues with adults Oppositional defiant disorder is a repeated pattern of negativistic, disobedient, hostile, defiant behavior toward authority figures, usually exhibited before 8 years of age.
An 18 year-old woman is brought to the emergency department by her two roommates after being found unconscious in the bathroom. Laboratory tests are ordered. The nurse reviewing the findings notes that the urinalysis is positive for flunitrazepam (Rohypnol). The nurse knows that flunitrazepam is often used:
As a date rape drug
A client is presented with the treatment option of electroconvulsive therapy (ECT). After discussion with staff members, the client requests that a family member be called to help make the decision about this treatment. What ethical principle does the nurse consider when supporting the client's request?
Autonomy Autonomy is the ethical principle of respecting the independence and right to self-determination of others. In this situation the nurse focuses on helping the client make a choice. Justice is the ethical principle that requires all people to be treated fairly, regardless of sex, age, religion, diagnosis, marital status, or socioeconomic level. Veracity is the ethical principle that requires truthfulness. Beneficence is the duty to do good and promote the welfare of others.
A child with attention deficit-hyperactivity disorder (ADHD) often becomes frustrated and loses control. A nurse uses a variety of graduated techniques to manage disruptive behaviors. List the following interventions in order, from the least invasive to the most invasive.
Avoiding situations that usually precipitate frustration Monitoring behavior for cues of rising anxiety Using a signal to remind the child to use self-control Refocusing the child's behavior with a specific directive Placing the child in a time-out
A 3-year-old child is found to have autism. Which behaviors should the nurse expect when observing this child? (Select all that apply.)
Avoids eye-to-eye contact Performs repetitive activities
The way individuals cope with an unexpected hospitalization depends on many factors. However, the one that is most significant is:
Basic personality
A nurse on the psychiatric unit is assigned to work with a male client who appears reclusive and distrustful of everyone. The nurse can help the client develop trust by:
Being prompt(신속한) for their scheduled meetings
Thirty minutes after administering fluphenazine (Prolixin) to a client, the nurse notes that the client's jaw is rigid, the client is drooling, and her speech is slurred. There are a number of as-needed prescriptions in the client's chart. What should the nurse administer?
Benztropine (Cogentin), 2 mg intramuscularly7
A parent whose daughter is killed in a school bus accident tearfully tells the nurse, "My daughter was just getting over the chickenpox and didn't want to go to school, but I insisted that she go. It's my fault that she's dead." How should the nurse anticipate that perceiving a death as preventable will likely influence the grieving process?
Bereavement may be of greater intensity and duration.
What should the nurse identify as the foremost basis for the development of schizophrenia?
Biological perspective
A nurse is caring for clients with a variety of psychiatric illnesses. For which diagnoses is the establishment of a psychiatric advance directive (PAD) most beneficial? (Select all that apply.)
Bipolar disease Paranoid schizophrenia
A nurse is speaking with a client who was sexually abused as a child. The client does not know what constitutes inappropriate touch by another person. What issue will have to be addressed with this client?
Boundary violations
The nurse is working with a client who talks freely about feeling depressed. During the interaction the client states, "Things will never change." What findings support the nurse's conclusion that the client is experiencing hopelessness? (Select all that apply.)
Bouts of crying Self-destructive acts Feelings of worthlessness
How should a nurse at an assisted living facility encourage a client to effectively complete the tasks of older adulthood?
By fostering a sense of contentment when the client looks back on her achievements
A hospitalized client with a borderline personality disorder consistently breaks the unit's rules. How will confronting the client about this behavior help the client?
By fostering self-awareness
A nurse is caring for a client with the diagnosis of somatoform disorder, conversion type. What type of affect does the nurse expect this client to exhibit? (Select all that apply.)
Calm Matter-of-fact
When planning care for an older client, the nurse remembers that aging has little effect on a client's:
Capacity to handle life's stresses An individual's ability to handle stress develops through experience with life; aging does not reduce this ability but often strengthens it. The senses of taste and smell are often diminished in the older individual. Muscle or motor strength is diminished in the older individual. Short-term memory is diminished in the older individual, whereas long-term memory remains strong.
What should a nurse recognize that a client who uses the defense mechanism of sublimation is doing?
Channeling unacceptable impulses into socially approved behavior
What should a nurse recognize that a client who uses the defense mechanism of sublimation is doing?
Channeling unacceptable impulses into socially approved behavior The individual using sublimation attempts to fulfill desires by selecting a socially acceptable activity rather than one that is socially unacceptable.
A nurse is teaching a client about side effects of medications. Which drug will cause a heightened skin reaction to sunlight?
Chlorpromazine Clients taking chlorpromazine should be instructed to stay out of the sun. Photosensitivity makes the skin more susceptible to burning.
A nurse suggests a crisis intervention group to a client experiencing a developmental crisis. The nurse knows that these groups are successful because the:
Client is assisted in investigating alternative approaches to solving the identified problem
A recently married 22-year-old woman is brought to the trauma center by the police. She has been robbed, beaten, and sexually assaulted. The client, although anxious and tearful, appears to be in control. The health care provider prescribes alprazolam (Xanax) 0.25 mg for agitation. The nurse should administer this medication when the:
Client requests something to calm her
A client is admitted for treatment of obsessive-compulsive disorder that is interfering with activities of daily living. Which medication should the nurse anticipate the health care provider will prescribe?
Clomipramine (Anafranil) Clomipramine (Anafranil) potentiates the effects of serotonin (antiobsessional effect) and norepinephrine in the central nervous system; it diminishes obsessive-compulsive behaviors. Benztropine (Cogentin) is an antiparkinsonian agent, not an antianxiety agent. Amantadine (Symmetrel) is an antiparkinsonian agent, not an antianxiety agent. Diphenhydramine (Benadryl) is an antihistamine, not an antianxiety agent.
A female nurse has been caring for a depressed 75-year-old woman who reminds her of her grandmother. The nurse spends extra time with her every day and brings her home-baked cookies. The nurse's behavior reflects:
Countertransference
A nurse is working with a couple and their two children. The 14-year-old son has been in trouble at school because of truancy and poor grades. The 16-year-old daughter is quiet and withdrawn and refuses to talk to her parents. The parents have had severe marital problems for the past 10 years. The priority nursing concern at this time is how the:
Couple's marital(결혼,부부 생활)의 problems are affecting their children
On the first day of the month a practitioner prescribes an antipsychotic medication for a client with schizophrenia. The initial dosage is 25 mg once a day, to be titrated in increments of 25 mg every other day to a desired dosage of 175 mg daily. On what day of the month will the client reach the desired daily dose of 175 mg?
Day 13 The client will reach the desired dosage of 175 mg on the 13th day of the month; on the first day it is 25 mg, on the third day it is 50 mg, on the fifth day it is 75 mg, on the seventh day it is 100 mg, on the ninth day it is 125 mg, on the 11th day it is 150 mg, and on the 13th day it is 175 mg.
A client with type 1 diabetes is found to have a psychosis and is to receive haloperidol (Haldol). Which response should a nurse anticipate with this drug combination?
Decreased control of the diabetes
A nurse concludes that a client's withdrawn behavior may temporarily provide a:
Defense against anxiety
In the process of development the individual strives to maintain, protect, and enhance the integrity of the self. The nurse determines that this is usually accomplished through the use of:
Defense mechanisms
A client on the psychiatric unit tells the nurse, "I'm a movie star, and the other clients are my audience." What is an appropriate conclusion for the nurse to document about what the client is experiencing?
Delusion of grandeur A delusion of grandeur is a fixed false belief that the person is a powerful, important person.
A client in the mental health clinic tells the nurse, "The FBI is out to kill me." What should the nurse document that the client is experiencing?
Delusion of persecution
An adolescent with a conduct disorder is undergoing behavioral therapy in an attempt to limit behaviors that violate societal norms. A specific outcome criterion unique to adolescents with this problem is:
Demonstration of respect for the rights of others
An older adult who lives alone tells a nurse at the community health center, "I really don't need anyone to talk to. The TV is my best friend." The nurse identifies the defense mechanism known as:
Denial
A female client who is severely incapacitated by obsessive-compulsive behavior has been admitted to the mental health hospital. The client's compulsive ritual involves changing her clothing 8 to 12 times a day. She continually asks the nurse for advice regarding her problems but then ignores it. This is an example of the conflict of:
Dependence versus independence
A female client is admitted to the hospital after attempting suicide. She reveals that her desire for sex has diminished since her child's birth 3 years ago. What is most directly related to the client's loss of interest in sex?
Depression
The nurse determines that the therapy that has the highest success rate for people with phobias is:
Desensitization involving relaxation techniques
Neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. What signs and symptoms of this syndrome should the nurse identify? (Select all that apply.)
Diaphoresis Hyperrigidity Hyperthermia as a result of dopamine blockade in the hypothalamus.
A client who is on the third day of detoxification therapy becomes agitated and restless. What are the signs and symptoms that indicate impending alcohol withdrawal delirium? (Select all that apply.)
Diaphoresis Tachycardia Hypertension
A client who is taking clozapine (Clozaril) calls the nurse in the psychiatric clinic to report the sudden development of a sore throat and a high fever. What should the nurse instruct the client to do?
Discontinue the medication and, if the health care provider is unavailable today, go to the emergency department for evaluation Symptoms of infection are suggestive of agranulocytosis, an adverse effect that can occur with clozapine therapy and can cause death.
A male long-distance jumper improves his distance by 3½ inches (7 cm) and earns the praise of his coach, but on another day, when he does not reach his mark, he forcefully kicks the door of his locker. What defense mechanism does his outburst demonstrate?
Displacement
A client who is in a manic phase of bipolar disorder threatens staff and clients on a psychiatric acute care unit. Place the following interventions in priority order, from the least to the most restrictive.
Diversional activities Limit-setting Medication administration Seclusion Restraints
A client's history demonstrates a pervasive pattern of unstable and intense relationships, impulsiveness, inappropriate anger, manipulation, offensive behavior, and hostility. The admitting diagnosis is borderline personality disorder. What does the nurse anticipate that this client may attempt to do?
Divide the staff into opposing factions to gain self-esteem
A parent of a 17-year-old girl who has been hospitalized for extremely disturbed acting-out behavior leaves a gift for the daughter but says, "I'm too busy to visit today." The daughter becomes upset and tearful after being given the message and opening the package. What does the nurse conclude that the parent's actions represent?
Double-bind message
A practitioner prescribes Alprazolam (Xanax) 0.25 mg by mouth three times a day for a client with anxiety and physical symptoms related to work pressures. For what most common side effect of this drug should the nurse monitor the client?
Drowsiness
A client with bipolar disorder is exhibiting accelerating activity and flight of ideas. What is the best nursing intervention to limit the accelerating manic behavior?
Engaging the client in conversation while walking slowly in the hall
A client is brought to the emergency department by friends because of increasingly bizarre behavior. Which signs does the nurse identify that indicate that the client was using cocaine? (Select all that apply.)
Euphoria Agitation Hypervigilance Impaired judgment
Risk for assaultive behavior is highest in the mental health client who:
Experiences command hallucinations
A client has just been admitted with the diagnosis of borderline personality disorder. There is a history of suicidal behavior and self-mutilation. The nurse remembers that the main reason that clients use self-mutilation is to:
Express anger or frustration
A client has just been admitted with the diagnosis of borderline personality disorder. There is a history of suicidal behavior and self-mutilation. The nurse remembers that the main reason that clients use self-mutilation 자해 is to:
Express anger or frustration
What should the nurse include when planning activities for an older nursing home resident with a diagnosis of dementia?
Familiar activities that the resident can complete successfully
A nurse is caring for a client with a bipolar disorder depressive episode. What should the nurse's objective for this client be?
Feeling comfortable with the nurse
The nurse explains to a nursing assistant that behavior usually is viewed and accepted as normal if it:
Fits within standards accepted by one's society
During an interview of a client with a diagnosis of bipolar I disorder, manic episode, the nurse expects the client to demonstrate:
Flight of ideas
During an interview of a client with a diagnosis of bipolar I disorder, manic episode, the nurse expects the client to demonstrate:
Flight of ideas Flight of ideas is a fragmented, pressured, nonsequential pattern of speech typically used during a manic episode.
Sildenafil (Viagra) is prescribed for a man with erectile dysfunction. A nurse teaches the client about common side effects of this drug. (Select all that apply.)
Flushing Headache Dyspepsia
A nurse is caring for a client who uses ritualistic behavior. What common antiobsessional medication does the nurse anticipate will be prescribed?
Fluvoxamine (Luvox)
After a traumatic event, a client is extremely upset and exhibits pressured and rambling speech. What therapeutic technique can the nurse use when a client's communication rambles?
Focusing Focusing is indicated when communication is vague; the nurse attempts to concentrate or focus the client's communication on one specific aspect. Touch invades the client's space and will not help focus the client's communication. Silence prolongs the rambling communication; the client needs to be focused. Until the concern is identified and explored, summarizing is impossible.
What is the best nursing intervention to encourage a socially withdrawn client to talk?
Focusing on nonthreatening subjects
According to Erikson, a person's adjustment to the period of senescence 노쇠 will depend largely on the adjustment the individual made to the earlier developmental stage of:
Generativity versus stagnation
According to Erikson, a person's adjustment to the period of senescence will depend largely on the adjustment the individual made to the earlier developmental stage of:
Generativity versus stagnation Erikson theorized that how well people adapt to the current stage depends on how well they adapted to the stage immediately preceding it—in this instance, adulthood.
A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the preceding month. Of which level of suicidal behavior is the client's behavior reflective?
Gestures
A nurse is planning activities for a withdrawn client who is hallucinating. Which activity will be most therapeutic for the client?
Going for a walk with the nurse Going for a walk with the nurse facilitates one-on-one interaction and the development of a trusting relationship.
The nurse is caring for a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis? (Select all that apply.)
Grandiosity 과장, 떠벌림 Talkativeness Distractibility
Relatives of the victims of a home invasion in which several family members were killed receive crisis intervention services. Which therapy is most beneficial after the immediate event has passed?
Grief
A frail, depressed client who frequently paces the halls becomes physically tired from the activity. What action should the nurse take to help reduce this activity?
Have the client perform simple, repetitive tasks
Imipramine (Tofranil), 75 mg three times per day, is prescribed for a client. What nursing action is appropriate when this medication is being administered?
Having the client checked for increased intraocular pressure and teaching about symptoms of glaucoma
An older client is transferred to a nursing home from a hospital with a diagnosis of dementia. One morning, after being in the nursing home for several days, the client is going to join a group of residents in recreational therapy. The nurse sees that the client has laid out several outfits on the bed but is still wearing nightclothes. What should the nurse do?
Help the client select appropriate attire and offer to help the client get dressed
Which feelings should a nurse anticipate a client with bulimia nervosa to report experiencing during an episode of binge eating? (Select all that apply.)
Hopelessness Powerlessness
A psychiatric nurse is hired to work in the psychiatric emergency department of a large teaching hospital. While reviewing the manuals, the nurse reads, "People with mental health emergencies shall be triaged within 5 minutes of entering the emergency department." What does the nurse consider this statement to represent?
Hospital policy
A nurse uses behavior modification to foster toilet-training efforts in a cognitively impaired child. What reward should the nurse provide to reinforce appropriate use of the toilet?
Hug with praise
A client tells the nurse, "That man on the television is talking only to me." What should the nurse document that the client is exhibiting?
Idea of reference An idea of reference, also called a delusion of reference, is a fixed, false personal belief that public events and people are connected directly to the client. An illusion is a misinterpretation of a sensory stimulus. A hallucination is a perceived experience that occurs in the absence of an actual sensory stimulus. Autistic thinking is a distortion in the thought process that is associated with schizophrenic disorders.
A nurse in the mental health clinic concludes that a client is using confabulation when:
Imagination is used to fill in memory gaps
A depressed client is admitted to the mental health unit. What factor should the nurse consider most important when evaluating the client's current risk for suicide?
Impending anniversary of the loss of a loved one
A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients?
Impulsive
The mother of an 18-year-old man comes to the local mental health center. She is extremely upset because of her son's behavior since the young man returned from his freshman year at college. He takes his brother's clothing, comes in at all hours, and refuses to get a job. Sometimes he is happy and outgoing, but at other times he is withdrawn. The mother asks why her son is like this. While contemplating this situation, the nurse considers that adolescents are usually:
Impulsive and self-centered
A 4-year-old child is found to have attention deficit-hyperactivity disorder (ADHD). What information about the child's behavior should the nurse expect when obtaining a health history from the parents? (Select all that apply.)
Impulsiveness Excessive talking Playing video games for hours on end Failure to follow through or finish tasks
The clients on a mental health unit go on a supervised day trip to a baseball game. When returning to the bus, a client with a narcissistic personality disorder insists on leaving the group to get an autograph from a player. What is the most appropriate response by the nurse?
Informing the client in a matter-of-fact tone that everyone must remain with the group
The nurse explains to the mother of a preschool child that Erikson identified the developmental conflict of children from 3 to 5 years as:
Initiative versus guilt Initiative versus guilt is the developmental conflict that faces the preschool child; the child will feel guilty if initiative is stifled by others.
When having a conversation with a nurse, an older client states, "I've lived a good life. I don't want to die, but I accept it as a part of life." What developmental stage, according to Erikson, has the client completed?
Integrity
A client with diabetes mellitus is able to discuss in detail the diabetic metabolic process while eating a piece of chocolate cake. What defense mechanism does the nurse identify when evaluating this behavior?
Intellectualization
To provide appropriate psychosocial support to clients, a nurse must understand development across the life span. What theory is the nurse using in considering relationships and resulting behaviors the central factors that influence development?
Interpersonal theory
A client with a history of alcoholism is found to have Wernicke encephalopathy associated with Korsakoff syndrome. What does the nurse anticipate will be prescribed?
Intramuscular injections of thiamine Thiamine is a coenzyme necessary for the production of energy from glucose. If thiamine is not present in adequate amounts, nerve activity is diminished and damage or degeneration of myelin sheaths occurs.
An adult is found to have schizotypal personality disorder. How should a nurse describe the client's behavior?
Introverted and emotionally withdrawn
A client with a history of sleeplessness, lack of interest in eating, and excessive purchases on charge accounts is seen in the mental health clinic. The adaptation that the nurse should expect the client to exhibit is:
Intrusive involvement with environmental activities
When answering questions from the family of a client with Alzheimer disease the nurse explains that the disease:
Is a slow, relentless deterioration of the mind
Survivors of a major earthquake are being interviewed on admission to the hospital. The nurse notes that they exhibit a flattened affect, make minimal eye contact, and speak in a monotone. These behaviors are indicative of the defense mechanism known as:
Isolation Isolation is the separation of thought or memory from feeling.
How can the nurse best minimize psychological stress in an anxious client who has been admitted to the psychiatric unit?
Learn what is of particular importance to the client
A client tells a nurse, "I have been having trouble sleeping and feel wide awake as soon as I get into bed." Which strategies should the nurse teach the client that will promote sleep? (Select all that apply.)
Leaving the bedroom when unable to sleep Exercising in the afternoon rather than in the evening Counting backward from 100 to 0 when his mind is racing
A nurse is caring for an adolescent client with the diagnosis of schizophrenia, undifferentiated type. Which signs and symptoms should the nurse expect the client to experience?
Loosened associations and hallucinations Loosened associations and hallucinations are the primary behaviors associated with a thought disorder such as schizophrenia. Paranoid delusions and hypervigilance are more common in paranoid-type schizophrenia than in the undifferentiated type
The nurse anticipates that the medication that will be used to prevent symptoms of withdrawal in clients with a long history of alcohol abuse is:
Lorazepam (Ativan)
A client with schizophrenia is started on an antipsychotic/neuroleptic medication. The nurse explains to a family member that this drug primarily is used to:
Make the client more receptive to psychotherapy
A nurse determines that a client is pretending to be ill. What does this behavior usually indicate?
Malingering
A health care provider prescribes divalproex (Depakote). What does the nurse consider an appropriate indication for the use of this drug?
Management of manic episodes of bipolar disorder
The parents of a child with attention deficit-hyperactivity disorder ask the nurse about using medication. What is the most frequently prescribed medication for this disorder?
Methylphenidate (Ritalin)
An obviously upset client comes to the mental health clinic and, after pushing ahead of the other clients, states, "I had an argument with my daughter, and now I'm tense, and worried, and angry." What level of anxiety does the nurse determine that the client is experiencing?
Moderate The client is focused on one part of reality but is unable to grasp the total picture; this situation reflects a moderate level of anxiety.
A client with schizophrenia who has type II (negative) symptoms is prescribed risperidone (Risperdal). Which outcomes indicate that the medication has minimized these symptoms? (Select all that apply.)
More interest is shown in unit activities. The client performs activities of daily living independently.
A client's admitting history indicates signs of akathisia. What clinical finding should the nurse expect when observing for this condition?
Motor restlessness
A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? (Select all that apply.)
Multiple losses Declines in health
A client is receiving doxepin (Sinequan). For which most dangerous side effect of tricyclic antidepressants should a nurse monitor the client?
Mydriasis Mydriatic action causes dilated pupils, which can precipitate an acute attack of glaucoma, resulting in blindness.
A client with schizophrenia repeatedly says to the nurse, "No moley, jandu!" The nurse determines that the client is exhibiting:
Neologism
Which tool is used to standardize and measure nursing treatments?
Nursing Interventions Classification (NIC)
A woman who was sexually assaulted by a stranger in the elevator of her apartment building is brought by her husband to the emergency department. What is the priority nursing intervention?
Obtaining information about her perception of the incident
A nurse is teaching clients about dietary restrictions during monoamine oxidase inhibitor (MAOI) therapy. What response does the nurse tell them to anticipate if they do not follow these restrictions?
Occipital headaches
What should the nurse do to develop a trusting relationship with a disturbed child who acts out?
Offer support and encourage safety during play activities Offering support and encouraging safety during play activities sets a foundation for trust because it allows the child to see that the nurse cares.
At a staff meeting, the question of a staff nurse's returning to work after completing a drug rehabilitation program is discussed. What is the most therapeutic way for the staff to handle the nurse's return?
Offering the nurse support in a straightforward manner
The nurse should first discuss terminating the nurse-client relationship with a client during the:
Orientation phase, when a contract is established
Methylphenidate (Ritalin) is prescribed to treat a 7-year-old child's attention deficit-hyperactivity disorder (ADHD). The nurse understands that methylphenidate is used in the treatment of this disorder in children for its:
Paradoxical effect
A male client with a diagnosis of antisocial personality disorder is admitted to the mental health hospital. What is the priority nursing intervention?
Presenting a united, consistent staff approach
A young client who has become a mother for the first time is anxious about her new parenting role. With the nurse's encouragement, she joins the new mothers' support group at the local YMCA. What kind of prevention does this activity reflect?
Primary prevention Primary prevention is directed toward health promotion and prevention of problems. Tertiary prevention is focused on rehabilitation and the reduction of residual effects of illness. Secondary prevention is related to early detection and treatment of problems.
A 23-year-old woman is admitted to a psychiatric unit after several episodes of uncontrolled rage at her parents' home, and borderline personality disorder is diagnosed. While watching a television newscast describing an incident of violence in the home, the client says, "People like that need to be put away before they kill someone." The nurse concludes that the client is using:
Projection
An older depressed person at an independent living facility constantly complains about her health problems to anyone who will listen. One day the client says, "I'm not going to any more activities. All these old crabby people do is talk about their problems." What defense mechanism does the nurse conclude that the client is using?
Projection The client is assigning to others those feelings and emotions that are unacceptable to him- or herself.
Which psychotherapeutic theory uses hypnosis, dream interpretation, and free association as methods to release repressed feelings?
Psychoanalytical model The psychoanalytical model studies the unconscious and uses the strategies of hypnosis, dream interpretation, and free association to encourage the release of repressed feelings. The behaviorist model holds that the self and mental symptoms are learned behaviors that persist because they are consciously rewarding to the individual; this model deals with behaviors on a conscious level of awareness. The psychobiological model views emotional and behavioral disturbances as stemming from a physical disease; abnormal behavior is directly attributed to a disease process. This model deals with behaviors on a conscious level of awareness. The social-interpersonal model affirms that crucial social processes are involved in the development and resolution of disturbed behavior; this model deals with behavior on a conscious level of awareness.
What should the nurse do when a client with the diagnosis of schizophrenia talks about being controlled by others?
React to the feeling tone of the client's delusion
A client who is being treated in a mental health clinic is to be discharged after several months of therapy. The client anxiously tells the nurse, "I don't know what I'll do when I can't see you anymore." The nurse determines that the client is:
Reacting to the planned discharge
A 30-year-old female client asks the nurse to change her room, stating that she hates her roommate and can't stand to be in the same room with her. Just as she finishes speaking, her roommate enters and the client tells her she missed her and has been all over the unit looking for her. The nurse recognizes that the client is using:
Reaction formation
What should a nurse ensure when creating an environment that is conducive to psychological safety?
Realistic limits are set.
What is the best nursing intervention when the language of a client in the manic phase of a bipolar disorder becomes vulgar and profane?
Recognizing that the behavior is part of the illness but setting limits on it
A client with a conversion disorder is experiencing paralysis of a leg. The nurse can expect this client to:
Recover use of the affected leg but, under stress, to again experience these symptoms
Unsatisfied needs create anxiety that motivates an individual to action. What should the nurse identify as the purpose for this action?
Reducing tension
A 13-year-old boy who recently was suspended from school for consistently bullying other children is brought to the pediatric mental health clinic by his mother. The child is assessed by the psychiatrist and referred to a psychologist for psychological testing. The day after the tests are completed, the mother returns to the clinic and asks the nurse for results of the tests. The nurse should:
Refer the mother to the psychiatrist
A nurse becomes aware of an older client's feeling of loneliness when the client states, "I only have a few friends. My daughter lives in another state and couldn't care less whether I live or die. She doesn't even know I'm in the hospital." The nurse identifies the client's communication as a:
Reflection of depression that is causing feelings of hopelessness
An older female client is concerned about maintaining her independent living status. What initial intervention strategy is of primary importance?
Reinforcing routines and supporting her usual habits
An older female client is concerned about maintaining her independent living status. What initial intervention strategy is of primary importance?
Reinforcing routines and supporting her usual habits The client has been able to function well up to this time, and her usual behaviors and routines should be supported. The data presented do not show a need to get the client help with cleaning and shopping, to write down and repeat information, or to set goals and time limits for the client's visits with the nurse.
A client is to begin lithium carbonate therapy. The nurse should ensure that before the drug's administration the client has baseline:
Renal studies
A nurse is caring for a group of children with the diagnosis of autism. Which signs and symptoms are associated with this disorder? (Select all that apply.)
Repetitive activities Self-injurious behaviors Lack of communication with others
Incidences of child molestation often are revealed years later when the victim is an adult. Which defense mechanism reflects this situation?
Repression Repression is a coping mechanism in which unacceptable feelings are kept out of conscious awareness; later, under stress or anxiety, thoughts or feelings surface and come into one's conscious awareness. Isolation is the separation of a thought from a feeling tone. Regression is the use of an unconscious coping mechanism through which a person avoids anxiety by returning to an earlier, more satisfying, or comfortable time in life. Introjection is the integration of the beliefs and values of another into one's own ego structure.
A nurse begins a therapeutic relationship with a client with the diagnosis of schizotypal personality disorder. What is the best initial nursing action?
Respecting the client's need for social isolation
A neuromuscular blocking agent is administered to a client before electroconvulsive therapy. At this time, the nurse should monitor the client for:
Respiratory difficulties
A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified (autistic disorder). What should the nurse consider most unusual for the child to demonstrate?
Responsiveness민감성 to the parents
Doxepin (Sinequan) is prescribed for a 74-year-old man for treatment of a depressive episode that has not responded to several other medications. The nurse in the outpatient clinic reviews with the client the side effects of doxepin. The identification of which side effects by the client as needing to be reported to the health care provider allows the nurse to conclude that the teaching has been effective? (Select all that apply.)
Retention of urine Thoughts of suicide
The nurse interviews a young female client with anorexia nervosa to obtain information for the nursing history. What will the client's history most likely reveal? (Select all that apply.)
Ritualistic behaviors Desire to improve her self-image
A 12-year-old child who has a history of school failure and destructive acting out is admitted to a child psychiatric unit with the diagnosis of conduct disorder. The youngest of three children, the child is identified by both the parents and the siblings as the family problem. The nurse recognizes the family's pattern of relating to the child as:
Scapegoating 심리) 전가(轉嫁) ((고통을 준 본인을 벌할 수 없을 경우 다른 사람을 공격하는 현상)) When all members of a family blame one member for all their problems, scapegoating is occurring.
When reviewing the medications for a group of clients on a psychiatric unit, the nurse concludes that the pharmacotherapy for anxiety disorders is moving away from benzodiazepines and moving toward:
Selective serotonin reuptake inhibitors Selective serotonin reuptake inhibitors have better safety profiles and do not carry the risk of substance abuse and tolerance.
An individual whose employment has been terminated because his company has been acquired by another company is brought by a family member to the mental health clinic because of extreme depression. While talking with the nurse the client says, "I'm a useless, worthless person. No wonder I lost my job." What type of delusion does the nurse identify?
Self-deprecation(자기비난 비하) The client's statement is self-derogatory and reflects a low self-appraisal.
A mother of a 6-year-old boy with the diagnosis of attention deficit-hyperactivity disorder (ADHD) tells the nurse that when she is reading storybooks to her son, about halfway through the story he becomes distracted, fidgets, and stops paying attention. The nurse suggests that the mother:
Shorten the rest of the story
What is the most appropriate intervention for the nurse to implement after finding a disturbed client in bed in the fetal position?
Sitting down in a chair by the client and saying, "I'm here to spend time with you."
What is the most appropriate intervention for the nurse to implement after finding a disturbed client in bed in the fetal position?
Sitting down in a chair by the client and saying, "I'm here to spend time with you." "I'm here to spend time with you" accepts the client at the client's current level and allows the client to set the pace of the relationship. Touching the client may be misinterpreted and may precipitate an aggressive response.
An autistic toddler is sitting in a corner, rocking and spinning a top. How can the nurse be most therapeutic when approaching this toddler?
Sitting with the toddler while watching the spinning top to provide a nonintrusive presence
A client with chronic undifferentiated schizophrenia is receiving an antipsychotic medication. For which potentially irreversible extrapyramidal side effect should a nurse monitor the client?
Tardive dyskinesia Tardive dyskinesia occurs as a late and persistent extrapyramidal complication of long-term antipsychotic therapy. It is most often manifested by abnormal movements of the lips, tongue, and mouth.
During a well-baby visit, the parents complain that their 2-year-old daughter soils herself because she is lazy. The parents plan to make her wear her soiled clothing to teach her a lesson. The nurse is concerned about the potential for child neglect and abuse. Which nursing intervention will be most therapeutic at this time?
Teaching the parents developmental milestones in relation to acceptable discipline methods
A nurse on the psychiatric unit of the hospital has been assigned four clients for the shift. The assignment includes an 84-year-old client who is severely depressed, a 73-year-old client who is being discharged, a 53-year-old client who was admitted for lithium toxicity, and a 48-year-old client who has panic attacks. Which client should the nurse evaluate first after receiving report?
The 53-year-old client should be evaluated first because of the severity of adaptations associated with lithium toxicity.
A teenager with anorexia nervosa is admitted to the adolescent unit of a mental health facility and signs a contract calling for her to gain weight or lose privileges. There is no weight gain after a week. What should the nurse explain to the client?
The prearranged consequences will go into effect.
A nurse, understanding the possible cause of alcohol-induced amnestic disorder, should take into consideration that the client is probably experiencing:
Thiamine deficiency
According to Erikson, a child's increased vulnerability to anxiety in response to separation or pending separation from significant others results from failure to complete a developmental stage. What does the nurse call this stage?
Trust Without the development of trust, the child has little confidence that the significant other will return; separation is considered abandonment by the child. Without identity, the individual will have a problem forming a social role and a sense of self; this results in identity diffusion and confusion. Without initiative, the individual will experience the development of guilt and feelings of inadequacy. Without autonomy, the individual has little self-confidence, develops a deep sense of shame and doubt, and learns to expect defeat.
A client's hands are raw and bloody from a ritual involving frequent handwashing. Which defense mechanism does the nurse identify?
Undoing
A secretary in a home health agency gossips about coworkers and then writes them notes to tell them how valuable they are to the organization and how much she likes working with them. What defense mechanism is being used by the secretary?
Undoing Undoing is atonement for or an attempt to dissipate unacceptable acts or wishes.
A nurse is caring for a client with antisocial personality disorder. What client characteristic should the nurse consider when formulating a plan of care?
Usually is unable to postpone gratification(희열) Individuals with antisocial personality disorder tend to be self-centered and impulsive. They lack judgment and self-control and are unable to postpone gratification. Generally they do not suffer from anxiety. These individuals believe that the rules do not apply to them, and they do not profit from their mistakes. These people are too self-centered to have a sense of responsibility to anyone.
A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? (Select all that apply.)
Verbalizes difficulty identifying personal strengths Acknowledges the effects of the addiction on the family Addresses how the addiction has contributed to family distress
A client in the early dementia stage of Alzheimer's disease is admitted to a long-term care facility. Which activities must the nurse initiate? (Select all that apply.)
Weighing the client once a week Having specialized rehabilitation equipment available Establishing a schedule with periods of rest after activities
What is the primary concern for a nurse caring for a client who is grossly impaired by stimulants?
What is the primary concern for a nurse caring for a client who is grossly impaired by stimulants?
A client with schizophrenia is actively psychotic, and a new medication regimen is prescribed. A student nurse asks the nurse, "Which of the medications will be the most helpful against the psychotic signs and symptoms?" What response should the nurse give?
Ziprasidone (Geodon) Ziprasidone (Geodon) is a neuroleptic, which will reduce psychosis by affecting the action of both dopamine and serotonin. Citalopram (Celexa) is a selective serotonin reuptake inhibitor antidepressant. Benztropine (Cogentin) is an anticholinergic. Acetaminophen with hydrocodone (Lortab) is an analgesic/opioid.
A client with depression is to be given fluoxetine (Prozac). What precaution should the nurse consider when initiating treatment with this drug?
he blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks. Fluoxetine (Prozac) does not produce an immediate effect; nursing measures must be continued to reduce the risk for suicide. Consuming milk and crackers to help prevent hyperacidity and discomfort is not necessary. Avoiding cheese, pickled herring, and wine is a precaution taken with the monoamine oxidase inhibitors. Weekly blood level checks are not necessary with Fluoxetine.
A 2½-year-old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. Child abuse is suspected. What statements might the nurse expect from a parent who engages in child abuse? (Select all that apply.)
"Every time I turn around the kid is falling over something." "I can't understand it. He didn't have a problem using the stairs without my help before this."
A nurse uses the CAGE screening test for alcoholism to determine an individual's potential for a drinking problem. What is one of the four questions included on this test?
"Have you ever felt bad or guilty about your drinking?"
A client is extremely depressed, and the practitioner prescribes a tricyclic antidepressant, imipramine (Tofranil). The client asks the nurse what the medication will do. The nurse responds:
"It will help increase your appetite and make you feel better."
A client is found to have paranoid schizophrenia, and the practitioner prescribes a typical antipsychotic medication. After a 1-month hospitalization the client is discharged home with instructions to continue the antipsychotic and a referral for weekly mental health counseling. The picture illustrates the client's physical status as observed by the nurse on the client's first visit to the community mental health clinic. What extrapyramidal side effect has developed?
Akathisia Akathisia, an extrapyramidal side effect of typical antipsychotics, is motor restlessness. The client is unable to sit or stand still and feels the need to move, pace, rock, swing the legs, or tap the feet. The condition occurs within 5 to 90 days of the initiation of therapy. Dystonia is muscle spasms of the face, tongue, head, neck, jaw, or back, usually resulting in exaggerated posturing. This extrapyramidal side effect of typical antipsychotics occurs within 1 hour to 1 week of the initiation of therapy. Tardive dyskinesia is facial, ocular, oral/buccal, lingual/masticatory, and systemic movements. This extrapyramidal side effect of typical antipsychotics may occur 6 months or more after the initiation of therapy. Pseudoparkinsonism has characteristics similar to those of Parkinson's disease (e.g., shuffling gait, tremors, rigidity, bradykinesia). This extrapyramidal side effect of typical antipsychotics may occur anytime after the initiation of therapy.
What is the most difficult initial task in the development of a nurse-client relationship?
Developing an awareness of self and the professional role in the relationship
An injured child is brought to the emergency department by the parents. While interviewing the parents, the nurse begins to suspect child abuse. Which parental behaviors might support this conclusion? (Select all that apply.)
Focusing on the child's role in sustaining the injury Changing the story of how the child sustained the injury Giving an explanation of how the injury occurred that is not consistent with the injury
The nurse is caring for a client with Alzheimer's disease who exhibits behaviors associated with hyperorality. To meet the client's need for a safe milieu, the nurse will instruct staff to monitor the client:
For attempts at eating inedible objects
What should the nurse do to achieve a primary objective of providing a therapeutic daycare environment for a client who is withdrawn and reclusive?
Foster a trusting relationship
A nurse encourages a client to attend Alcoholics Anonymous (AA) meetings after discharge. What do self-help groups such as AA help their members do?
Foster changes in behavior
A health care provider refers a 52-year-old man to the mental health clinic. The history reveals that the man lost his wife to colon cancer 6 months ago and that since that time he has seen his health care provider seven times with the concern that he has colon cancer. All tests have had negative results. Recently the client stopped seeing friends, dropped his hobbies, and stayed home to rest. Which disorder should the nurse identify as consistent with the client's preoccupation with the fear of having a serious disease?
Hypochondriac disorder
A depressed client is admitted to the mental health unit. What factor should the nurse consider most important when evaluating the client's current risk for suicide?
Impending anniversary of the loss of a loved one The anniversary frequently reemphasizes the feeling of loss and abandonment and serves to heighten current feelings of depression and hopelessness.
A college student is brought to the mental health clinic by his parents. The diagnosis is borderline personality disorder. Which factors in the client's history support this diagnosis? (Select all that apply.)
Impulsiveness Lability of mood Self-destructive behavior
A 25-year-old woman is seeking outpatient counseling after thinking about suicide. The nurse realizes that there some factors place individuals at a higher risk for suicide. Which of these factors increases the risk for suicide? (Select all that apply.)
Impulsivity Panic attacks Unemployment Substance abuse
A nurse is evaluating a young adult for evidence of achievement of the age-related developmental stage set forth in Erikson's developmental theory. What developmental crisis is associated with this age group?
Intimacy versus isolation
A client who had to be cut out of a car after a motor vehicle collision has no visible physical effects from the ordeal. The client responds to the emergency department nurse's questions factually in a soft voice with a composed manner. This behavior may indicate that the client:
Is controlling the expression of feelings
A nurse is working with an adolescent client with conduct disorder. Which strategies should the nurse implement while working on the goal of increasing the client's ability to meet personal needs without manipulating others? (Select all that apply.)
Provide physical outlets for aggressive feelings Establish a contract regarding manipulative behavior Develop activities that provide opportunities for success
A child is found to have attention deficit-hyperactivity disorder (ADHD). What strategy should the nurse teach the parents to help them cope with this disorder?
Reward appropriate conduct
A client receiving the medication buspirone hydrochloride (Buspar) is admitted to the hospital with the diagnosis of possible hepatitis. The nurse identifies that the client's sclerae look yellow. What should be the nurse's initial action?
Withhold the medication The medication should be stopped immediately because jaundice indicates possible liver damage, which prolongs elimination of the drug and may result in toxic accumulation. Milk does not change the effect of the drug. The drug must be stopped, not reduced. The drug is available only in an oral form; in addition, the route of administration will not influence the occurrence of toxic accumulation.
What clinical findings may be expected when a nurse cares for an individual with an anxiety disorder? (Select all that apply.)
Worrying about a variety of issues Converting the anxiety into a physical symptom Displacing the anxiety onto a less threatening object Demonstrating behavior common to an earlier stage of development
For which adverse effect should the nurse continually observe a client who is receiving valproic acid (Depakene)?
Yellow sclerae
