Evolve Saunders MH FORTIS

The husband of an alcohol-troubled wife says, "If anyone had said I'd be henpecked, I'd have called them a liar, but now I realize that I'm codependent." Which statement by the nurse would be therapeutic?

"Can you tell me more about that? You see yourself as being codependent with your wife?"

A 37-year-old client who is recovering from benzodiazepine dependence says, "I think I've walked under a black cloud. I've lost so many people. First, my brother dies of the big C; then my husband leaves me for a 20-year-old bimbo. I wish I had a Xanax right now." Which statement by the nurse would be therapeutic?

"Can you tell me what you think the Xanax can do for you? Are there other things you used to do that might help you just as well?"

Which statement made by an unlicensed assistive personnel (UAP) indicates to the registered nurse that the UAP understands the concepts related to suicide?

"Discussing suicide with a client is not harmful."

A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern?

"Do you feel afraid that people are trying to hurt you?"

The nurse is performing an admission assessment on a client at high risk for suicide. The nurse should prepare to ask the client which assessment question to elicit data related to this risk?

"Do you have a plan to commit suicide?"

The spouse of an alcoholic client is attending a support group and says to the group members, "It's all very well for everyone to label me an enabler, but if I didn't call him in sick at work, he'd lose his job. Where would we be then?" Which statement by the nurse co-leader would be therapeutic?

"Do you know that enabling creates codependency? Isn't viewing his failure as yours significant?"

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

"Have you shared your concerns with the police?"

A 10-year-old girl who has been referred for evaluation for drawing sexually explicit scenes in her textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms?

"I am concerned about you. Are you now or have you ever been abused?"

The nurse in the mental health unit is having a conversation with a client diagnosed with posttraumatic stress disorder. The client seems upset and looks anxious. What is the appropriate nursing statement the nurse should make to the client?

"I can see that you are upset."

A hospitalized client with a diagnosis of schizophrenia who is experiencing delusions says to the nurse, "I know that the doctor is talking to the top man in the mob to get rid of me." Which response should the nurse make to the client?

"I don't know anything about the top man in the mob. Do you feel afraid that people are trying to hurt you?"

The nurse is performing an assessment on a 16-year-old female client who has been diagnosed with anorexia nervosa. Which statement, if made by the client, would the nurse identify as necessitating further assessment on a priority basis?

"I exercise 3 to 4 hours every day to keep my slim figure."

A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse?

"I hear what you are saying, but I don't share your belief."

Which piece of subjective data obtained during assessment of a severely anxious client would indicate the possibility of posttraumatic stress disorder?

"I keep reliving the abuse."

A home health nurse is talking to the spouse of a client who is taking an antidepressant. The spouse says, "Now that my husband is responding to the antidepressant, the suicidal risk is over and you can stop making these home visits." After analyzing this statement, which is the appropriate nursing response?

"I need to continue with my visits. Most suicides occur within 3 months after improvement begins, because the client now has the energy to carry out the suicidal intentions."

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement?

"I no longer feel that I deserve the beatings my husband inflicts on me."

A client hospitalized in the mental health unit with depression is preparing to be discharged to outpatient status. The nurse is discussing termination and follow-up plans with the client. Which client statement would most concern the nurse about the client's discharge and indicate the need for follow-up treatment?

"I think I really couldn't have worked that job even if the man had given me the time he should have during the interview. It's just as well. I really didn't want a job where I had to work such long hours. But I had good reason to get depressed and end up here. But it all worked out. I really didn't want that job anyway."

When planning discharge care for a client with bipolar disorder, the nurse determines the need for further teaching when the client makes which statement?

"I will take the medicine until I am sure I am feeling well enough to handle my problems again."

A client tentatively diagnosed with a borderline personality disorder says to the nurse, "I don't know why I got my tattoo; it was for me. OK? Sometimes I do these things to get my parents mad, and sometimes I do them because I'm bored. That's what happened the night I crashed the family car. I wasn't drunk or suicidal or anything like the police thought. It was just for kicks!" Which is the appropriate nursing response?

"It is scary when you feel out of control with such feelings of emptiness and anger that you can't stop yourself."

Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of blood, the client begins to shout, "You're all vampires. Let me out of here!" Which is the appropriate nursing response?

"It must be frightening to think that others want to hurt you."

The client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy?

"It provides a negative reinforcement when the stimulus is produced."

A 15-year-old client who is pregnant and unwed tells the nurse, "My life was unbearable before I met Johnny. My mother beats me up every day, and my dad has been sleeping with me since I was 10 years old!" Which response is appropriate for the nurse to make?

"It seems that you needed help to separate from your family. Do you feel you are ready to have a baby with Johnny?"

A nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." Which response should the nurse make to the client?

"It sounds as though you are feeling all alone right now."

A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). The client is calm, but the client's daughter is hypervigilant and anxious. The daughter says to the nurse, "My mother's brain will be shocked with electricity. How can the doctor even think about doing this to her?" Which response by the nurse is therapeutic?

"It sounds as though you are very concerned about the procedure. Let's discuss the procedure."

A nursing student is assisting with the care of a client with a chronic mental illness. The nurse informs the student that a behavior modification approach (operant conditioning) will be used in treatment for the client. Which statement by the student indicates a need for further information about the therapy?

"It uses negative reinforcement."

A 63-year-old woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic?

"It's OK to grieve and be angry with your daughter and anyone else for a time."

A client with a diagnosis of depression has been meeting with the mental health nurse for therapy sessions for the past 6 weeks. During the session the client says to the nurse, "I lost my job this week, and I'm going to be evicted from my apartment if I can't pay my bill. The only person that I have is my daughter, but I don't want to burden her with my problems." Which response by the nurse would be therapeutic?

"Let's talk about contacting your daughter. Wouldn't you want to know if your daughter was having difficulty and try to help her if you could?"

Which statement, if made by a client who has recently experienced an emotional crisis, is most likely to assure the nurse that she has returned to her pre-crisis level of functioning?

"My boss tells me that I'm being considered for a promotion and a raise."

A clinic nurse is monitoring a client with anorexia nervosa. Which statement, if made by a client, should indicate to the nurse that treatment has been effective?

"My friends and I went out to lunch today."

A nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." Which is the appropriate response by the nurse?

"Our relationship is a therapeutic and helping one."

A battered wife says, "My husband never beat me up, so I didn't think he was abusive even after he lost all our money through bad deals, bullying me into his schemes, gambling, womanizing, and now not holding a real job with benefits. I still let him refinance our mortgage, take money out of the bank, and put the house in his name." Which statement by the nurse is therapeutic?

"So you realize that there are many ways to erode someone's self-confidence and independence? Can you share with me some ways that you feel you can cope with this abuse?"

A nurse working in an urgent care center is interviewing a woman with vague somatic complaints. The client states that she was raped a few weeks ago but still feels "as if it just happened to me." Which therapeutic response should the nurse make to the client?

"Tell me more about what happened, and what causes you to feel like the rape just occurred."

A client is planning to attend Overeaters Anonymous. Which statement by the client indicates a need for additional information regarding this self-help group?

"The leader is a nurse or psychiatrist."

A nurse should interpret that which comment by a client whose husband uses violence against her is consistent with the presence of low self-esteem commonly found with battered wife syndrome?

"Things would be fine at home if I just could do better. He has a lot of pressures on him at work."

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy?

"This form of therapy provides a negative reinforcement when the stimulus is produced."

During a therapy session with a client with paranoid disorder, the client says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would be therapeutic?

"We are not here to discuss how I look or smell. We are here to talk about you."

A nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which is the therapeutic response by the nurse?

"What aspects of this situation are the most difficult for you?"

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." What is the most helpful response by the nurse?

"What do you find difficult about this situation?"

A client with a potential for violence is exhibiting aggressive gestures, making belligerent comments to the other clients, and is continuously pacing in the hallway. Which comment by the nurse would be therapeutic at this time?

"What is causing you to become agitated?"

The nurse is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, what is the most appropriate question?

"What leads you to seek help now?"

A nurse is developing a care plan that will include goals that will help the client achieve an optimal level of functioning and appropriate resource utilization. When the nurse enters the client's room, the client asks the nurse, "Could you ask the health care provider (HCP) to let me have a pass for the weekend?" Which response is appropriate that assists the client in achieving these goals?

"When the HCP arrives on the unit, I will let them know that you have a question."

A nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, "I haven't had an appetite at all for the last few weeks." Which best response should the nurse make?

"You haven't had an appetite at all?"

A client admitted to the mental health unit with depression states to the nurse, "My life has been such a failure. Nothing I do turns out right." Which therapeutic response should the nurse make?

"You seem very discouraged. Can you think of anything recently that went as you planned?"

A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." What is the nurse's best response?

"You sound very upset. Are you thinking of hurting yourself?"

A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic?

"You're feeling angry that your family continues to hope for you to be cured?"

When the mental health nurse visits a client at home, the client states, "I haven't slept at all the last couple of nights." Which response by the nurse illustrates a therapeutic communication response to this client?

"You're having difficulty sleeping?"

The nurse in the mental health unit is assigned to care for a female client with a diagnosis of acute depression. In communicating with the client, which statement would be appropriate for the nurse to make?

"You're wearing a new blouse."

A client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication?

"You've been feeling like a failure for a while?"

The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response would be therapeutic?

"Your health care provider wants you to continue with this medication because it is helping you. Do you recall needing to be hospitalized because you stopped your medication?"

An acutely depressed client is receiving cognitive-behavioral therapy. The nurse is developing a plan of care for the client and includes interventions that focus on this type of therapy. Which interventions should the nurse include? Select all that apply.

1. Assisting the client to identify and test negative cognition 2. Assisting the client to participate in the treatment process 3. Assisting the client to develop alternative thinking patterns 4. Assisting the client to rehearse new cognitive and behavioral responses

The nurse is preparing a care plan for a client exhibiting negative symptoms of schizophrenia. Which are indicative of negative symptoms? Select all that apply.

1. Short attention span 2. Limited ability to communicate verbally

Which are characteristics of the termination stage of group development? Select all that apply.

1. The group evaluates the experience. 2. The group explores members' feelings about the group and the impending separation.

The nurse is preparing a client for electroconvulsive therapy (ECT), which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply.

1. Obtain an informed consent. 2. Have the client void before the procedure. 3. Remove dentures and contact lenses before the procedure. 4. Withhold food and fluids for 6 hours before the treatment.

The nurse is planning to formulate a psychotherapy group. Several clients are interested in attending the session. The nurse plans the group, knowing that which is the maximum number of group members that can be included?

8

A nurse is planning care for a group of clients on a mental health unit. The nurse notes that most of the assigned clients require interventions commonly used to treat anxiety disorders. Such anti-anxiety interventions would be appropriate for which clients? Select all that apply.

A client with panic disorder Generalized anxiety disorder A client with posttraumatic stress disorder (PTSD) A client with obsessive-compulsive disorder (OCD)

A nurse is admitting a client who is in a state of starvation because of anorexia nervosa. Which roommate choice is least appropriate for this client?

A client with pneumonia

The nurse is caring for a client with a diagnosis of agoraphobia. When communicating with the client about the disorder, the nurse should expect the client to describe which behavior?

A fear of leaving the house

Which describes the primary focus of milieu therapy?

A living, learning, or working environment

A mental health nurse who has been meeting with a client with a diagnosis of post-traumatic stress disorder is in the termination phase of the nurse-client relationship. The nurse notes that the client has been quiet and withdrawn. Which interpretation should the nurse make about the client's behavior?

A normal behavior that can occur during termination

A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention?

A structured program of activities in which the client can participate

On review of the client's record, the nurse notes that the mental health admission was voluntary. Based on this information, the nurse anticipates which client behavior?

A willingness to participate in the planning of the care and treatment plan.

The nurse is admitting a client with a diagnosis of posttraumatic stress disorder to the mental health unit. The client is confused and disoriented. During the assessment, what is the nurse's primary goal for this client?

Accept the client and make the client feel safe.

The nurse employed in a mental health unit of a hospital is the leader of a group psychotherapy session. What is the nurse's role during the termination stage of group development?

Acknowledging the contributions of each group member

The nurse is assessing a client in the coronary care unit (CCU) who seems to fluctuate in his ability to focus during the day. On the basis of this assessment, which client problem should the nurse suspect?

Acute confusion as a result of CCU psychosis

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program?

Admitting to having a problem

The nurse is caring for a client with Alzheimer's disease who is having difficulty recognizing objects that are well known, including people. The nurse determines that the client is experiencing which problem?

Agnosia

The nurse in a mental health clinic is reviewing the records of the clients to be seen that day. The nurse determines that which client is at highest risk for suicide?

An 18-year-old alcohol- and drug-abusing youth who must tell his parents that he failed to pass an examination required for graduation from high school

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation?

An expected coping mechanism

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care?

Ask the client about the amount of drug use and its effect.

A nurse is performing an assessment on a client being admitted to the mental health unit. During the interview, the nurse discovers that the client suffered a severe emotional trauma 1 month earlier and is now experiencing paralysis of the right arm. Which is the initial nursing action?

Assess the client for organic causes of the paralysis.

A client with a history of panic disorder comes to the emergency department and states to the nurse: "Please help me—I think I'm having a heart attack." What is the priority nursing action?

Assess the client's vital signs.

A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action?

Assigning a staff member to the client who will remain with the client at all times

Which is the primary goal of crisis intervention therapy?

Assist the client in returning to the level of pre-crisis functioning.

The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia?

Atrophy of the lateral and/or third ventricles of the brain

The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction should the nurse provide to the staff?

Avoid laughing or whispering in front of the client.

A client has been admitted to the inpatient psychiatric unit because the client has displayed violent behavior and is at risk for potentially harming others. What should the nurse avoid doing when caring for this client?

Closing the door to the client's room when giving care to the client

The nurse should include which information in the medication teaching plan for a client diagnosed with schizophrenia?

Coffee, tea, and soda consumption should be limited.

A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. Which condition will be the focus of this consult?

Conversion disorder

A client admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit door shouting, "Let me out. There's nothing wrong with me. I don't belong here." What defense mechanism is the client implementing?

Denial

A client being seen in the emergency department immediately after being sexually assaulted appears calm and controlled. The nurse analyzes this behavior as indicating which defense mechanism?

Denial

The history assessment of a client diagnosed with schizophrenia confirms a routine that includes smoking two packs of cigarettes and drinking 10 cups of coffee daily. The nurse recognizes that which is the greatest risk for injury these behaviors present for this client?

Diminishing the effectiveness of psychotropic medication

A client who is exhibiting psychotic behaviors is admitted to the psychiatric unit. In developing a plan of care, the nurse should identify which as the priority client problem?

Disturbed thought processes

The health care provider has prescribed medication therapy for a client with an alcohol abuse problem to assist in the maintenance of sobriety. The nurse reviews the client's record and expects to note that which medication has been prescribed?

Disulfiram (Antabuse)

A client recently admitted to the hospital in the manic phase of bipolar disorder is dehydrated, unkempt, taking antipsychotic medications, and complaining of abdominal fullness and discomfort. The nurse determines that which intervention is most appropriate for these complaints?

Encourage frequent fluid intake and a high-fiber diet.

A nurse is conducting a group therapy session when a client who has shared with the group at a previous session that she isolates herself when she feels depressed, suddenly gets up to leave. Which is the appropriate nursing action?

Encourage the client to stay, and ask the client what she is feeling.

A female client in a manic state emerges from her hospital room. She is topless and is making sexual remarks and gestures toward the staff and other clients. Which is the best initial nursing action?

Escort the client to her room and assist her in getting dressed.

A manic client begins to make sexual advance towards visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement?

Escort the client to their room, with the assistance of other staff.

A nurse is developing a plan of care for a client at high risk for suicide who was just admitted to the psychiatric unit. The focus of the plan is to promote a safe and therapeutic environment. Which intervention should the nurse include in the plan of care?

Establish a therapeutic relationship.

Which subject should the nurse address in preparing for the orientation phase of the therapeutic relationship?

Establishing the parameters of the relationship

A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes were much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior?

Evidence of the client's disturbed body image

A postsurgical client with a history of heavy alcohol intake has returned to the nursing unit. Which signs/symptoms of delirium tremens (DTs) should the nurse plan to continuously assess for?

Fever, hypertension, changes in level of consciousness, and hallucinations

A woman who is a victim of family violence is now engaged in group therapy sessions. She begins yelling at another client during the therapy session and screams, "I can't listen to this. You people are no different from the ones at home." The client stands up and tips the chair over backward. What is the nurse's immediate action?

Firmly reinforce group rules to the woman, stating that aggressive yelling is not acceptable in the group.

The nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse should assign priority to which assessment finding?

Fist clenched, pounding table, fearful

When admitting a client to the mental health unit who has a history of hallucinogenic drug use, the nurse should be prepared to manage which occurrences unique to abuse of this classification of drugs?

Flashbacks

A nurse is monitoring a group therapy session. During this session the members are identifying tasks and boundaries. The nurse determines that these activities are characteristic of which stage of group development?

Forming

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as, "I'm such a failure. I can't do anything right." Which is the best nursing response?

Identify recent behaviors or accomplishments that demonstrate the client's skills.

During the admission assessment process, the nurse observes that a client with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likely the result of which client factor?

Impaired pain perception

The mental health nurse is conducting a group therapy session and is monitoring a client with a diagnosis of agoraphobia who has been attending the sessions for several months. The nurse notes that the client is cooperative, sharing with peers, and making appropriate suggestions during group discussions. How should the nurse interpret this behavior?

Improvement

A nurse is developing a plan of care for the client who is upset following the loss of a job. The client is verbalizing concerns regarding the ability to meet financial obligations. Which is the appropriate client problem?

Inability to meet role expectations

The nurse is monitoring a client with a diagnosis of schizophrenia. The nurse notes that the client's emotional responses to situations occurring throughout the day are incongruent with the tone of the situation. The nurse should document the findings using which description of the client's behavioral response?

Inappropriate affect

The nurse is planning care for a client with bipolar disorder who is experiencing psychomotor agitation. Which activity should the nurse plan for this client?

Including the client in a clay-molding class that is scheduled for today

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan

Increasing the level of suicide precautions

A nurse is preparing to develop a care plan for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder (OCD). The nurse should plan to include which component as a priority in the nursing plan of care?

Individualized goals and objectives

The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate?

Interrupt the client and offer to take her for a walk.

The nurse is providing a health promotion session to a group of teenagers and is discussing the abuse of barbiturates. The nurse should provide which information to the teenagers?

Is the cause of many drug overdose deaths

The nurse understands that which best describes Gestalt therapy?

It emphasizes self-expression, self-exploration, and self-awareness in the present.

The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority problem for this client?

Lack of ability to cope effectively

The client with a diagnosis of dependent personality disorder is most likely to have problems coping with which issue?

Making decisions

Which are the most likely characteristics of an alcohol abuser? Select all that apply.

Male Suicidal at least once Abusing drugs as well as alcohol

A nurse is preparing for the arrival of a new client at a drug abusers' residential treatment center and prepares to explain to the client that the emphasis of the center is on group and social interaction, and that rules and expectations are mediated by peer pressure. Which is the most likely focus of therapy of this residential center?

Milieu therapy

Which type of therapeutic approach has the characteristic that all team members are seen as equally important in helping clients meet their goals?

Milieu therapy

When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client?

Monitor closely for harm to self or others.

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.

Monitor vital signs. 3. Provide a safe environment. 4. Address hallucinations therapeutically. 6. Provide reality orientation as appropriate.

A nurse should monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal?

Nausea, vomiting, diarrhea, muscle aches, and diaphoresis

The nurse is monitoring a client who has been placed in restraints because of violent behavior. When should the nurse determine that it will be safe to remove the restraints?

No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints.

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action?

Nonstop physical activity and poor nutritional intake

The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors?

Normal reactions to a devastating event

The nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action?

Observing rigid rules and regulations

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?

Observing rigid rules and regulations

A nurse is performing an assessment on a client admitted to the mental health unit. The client tells the nurse that she cannot leave home without checking numerous times that the iron and coffee pot have been shut off. The client states that this activity makes her late for many functions and that she misses engagements on occasion because of it. The nurse would expect to note which anxiety disorder documented in the client's record?

Obsessive-compulsive disorder (OCD)

The day nurses in a psychiatric unit are receiving report from the night shift. While this is occurring, a client approaches the nurses' station, becomes very loud and offensive, and demands to be seen by the health care provider (HCP) immediately. Which is the appropriate nursing intervention?

Offer to assist the client to an examination room until the HCP is notified.

The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care?

One-to-one suicide precautions

Which is a common outcome that results from the effect of methamphetamine abuse on the vascular system?

Poor wound healing

The nurse is planning a stress management seminar for clients in an ambulatory care setting. Which concept should the nurse plan to include in the content of the seminar?

Progressive muscle relaxation techniques are useful for easing tension from many causes.

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, what is the nurse's immediate priority of care?

Provide safety for the client and other clients on the unit.

A nurse is assigned to a client who is psychotic, pacing, agitated, and using aggressive gestures and rapid speech. The nurse should determine that which action is the priority of care at this time?

Providing safety for the client and other clients on the unit

A homeless shelter has sustained severe damage as a result of a fire, and most of the structure and people's belongings were destroyed. Ten of the individuals who are being displaced have a history of chronic mental illness. The mental health team coordinating support initially should focus their efforts on which action?

Providing the clients with shelter, clothing, and food

A client is found to have rape trauma syndrome. The nurse plans care for the client knowing that which occurs in this condition?

Re-experiencing recollections of the trauma

A client comes to the emergency department following an assault and is extremely agitated, trembling, and hyperventilating. What is the appropriate initial nursing action?

Remain with the client until the anxiety decreases.

A client comes into the emergency department in a severe state of anxiety after a car crash. Which is the appropriate nursing intervention?

Remain with the client.

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action?

Removing the client from any immediate danger

The nurse in the mental health unit recognizes which as being therapeutic communication techniques? Select all that apply.

Restating Listening Maintaining neutral responses Providing acknowledgment and feedback

The mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter stashes food, eats all the foods that make her hyperactive, and hangs out with the "wrong crowd." In helping the mother prepare for her daughter's discharge, what instruction should the nurse provide?

Restrict the amount of chocolate and caffeine products in the home.

A nurse is preparing a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to improve communication. Which should the nurse include in the plan of care?

Reward the client when a desired behavior is performed.

The nurse is developing a plan of care for a client who is scheduled to have electroconvulsive therapy (ECT). Which problem is a priority for this client?

Risk for aspiration

A client tentatively diagnosed with a borderline personality is admitted to the psychiatric unit for control of symptoms. Based on an understanding of personality disorders, the nurse should determine that which problem is the priority?

Risk for self-harm

A nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center to plan activities that will meet the child's needs. Which should have the priority consideration in planning activities for the child?

Safety with activities

A client is admitted to the hospital with a diagnosis of major depression, severe, single episode. The nurse assesses the client and notes that the client has poor nutritional intake. Which is the appropriate nursing intervention?

Schedule brief nursing interactions with the client during several meals in which small portions are offered.

The mental health nurse is talking to a client who has been diagnosed with posttraumatic stress disorder. During the conversation, the nurse notes that the client is exhibiting a paranoid stare and that he begins to pace and fidget. What is the appropriate nursing intervention?

Share the observation with the client and help the client to recognize his feelings.

The nurse is developing a discharge plan for the family of a client diagnosed with a mood disorder. The nurse should plan to include which priority information to the family?

Signs that the client may be considering suicide

A client is unwilling to go out of the house for fear of "making a fool of myself in public." Because of this fear, the client remains homebound. Based on these data, which mental health disorder is the client experiencing?

Social phobia

A nurse is gathering data from a client with a phobia. The client tells the nurse that he consistently avoids attending community functions because he fears that he will be asked to speak publicly to the members. On the basis of this information, the nurse determines that the client is experiencing which condition?

Social phobia

A nurse is reviewing the assessment findings documented in the chart of a client who is newly admitted to the mental health unit. The nurse notes that the client has experienced emotional turmoil and is exhibiting signs and symptoms that usually result from a loss of physical functioning, although no such loss can be confirmed medically. The nurse interprets these findings as indicating which condition?

Somatization disorder

A client admitted to the mental health unit with major depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today the client appears in the dayroom dressed and well groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. Which initial action should the nurse take after noting this client's behavior?

Speak to the client personally about the nurse's observations, and ask if the client is thinking about suicide.

Which are characteristics of seasonal affective disorder (SAD)? Select all that apply.

Stimulates a craving for carbohydrates 3. Is related to abnormal melatonin metabolism 5. Improves during the spring and summer months 6. Is a result of alterations in the available amounts of sunlight

While being treated, a client is introduced to short periods of exposure to the phobic object while in a relaxed state. What term is used to describe this form of behavior modification?

Systematic desensitization

A client's unresolved feelings related to loss would be most likely observed during which phase of the therapeutic nurse-client relationship?

Termination

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?

The adolescent gives away a DVD and a cherished autographed picture of a performer.

A mental health nurse notes that a client with schizophrenia is exhibiting an immobile facial expression and a blank look. Which should the nurse document in the client's record?

The client has a flat affect.

A nurse is assessing a client in crisis and is determining the potential for self-harm. Which assessment data would indicate that the client is at very high risk for suicide?

The client has an immediate plan for a suicide attempt.

A nurse who is reviewing the record of a client admitted to the mental health unit notes that the client was admitted by voluntary status. Which statement describes voluntary status?

The client has the right to demand and obtain release from the hospital.

A nurse in the emergency department is preparing to care for a client who has just been sexually assaulted. Which client behavior demonstrates denial?

The client is calm and quiet.

A client with a history of anxiety appears to be in the second phase of crisis response. The nurse prepares for the possibility that which will occur?

The client will employ new coping methods that will resolve the problem.

The nurse has been working with a victim of rape in a clinic setting for the past 4 weeks. Which would be unrealistic as a short-term initial goal for this client?

The client will resolve feelings of fear and anxiety related to the rape trauma.

A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively with the situation. Which is the least realistic goal for this client?

The client will stop blaming himself for the lack of insurance.

The nurse is monitoring a woman with a diagnosis of depression. Which behavior, if observed by the nurse, indicates that suicide precautions should be implemented for this client?

The woman asks to meet with a lawyer to take care of unfinished business.

The nurse should provide which information to the parents of a teenager about their child's new diagnosis of schizophrenia?

Their child likely has an imbalance of the chemical dopamine.

A 45-year-old client states that he used to drink a cocktail nightly after work and also had a drink with his meal. Now he has two drinks before dinner and two or three more drinks during his meal. As the client continues to describe his alcohol intake, the nurse discovers that he also has added a couple of drinks at night to help him sleep. Which is the most accurate assessment of his alcohol consumption?

Tolerance

An older client with delirium becomes agitated and confused at night. Which action should be the nurse's most important strategy to help this client?

Turn off the television and radio, and use a nightlight.

A mental health nurse asks a nurse orientee to describe the underlying pathophysiology associated with acts of compulsion, such as repeated hand washing, performed by clients with obsessive-compulsive disorder (OCD). The nurse determines that the orientee understands this disorder if the orientee identifies which characteristic of the client?

Unconsciously controlling unpleasant thoughts or feelings

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?

Use an indirect light source and turn off the television.

A nurse is developing a plan of care for a client with a psychotic disorder who is experiencing altered thoughts that include the belief food is being poisoned. Which strategy should the nurse plan to implement that will encourage the client to discuss feelings?

Use open-ended questions and silence.

A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat?

Using open-ended questions and silence

Thiamine supplementation and other nutritional vitamin support measures are prescribed for clients who have been using alcohol to prevent or decrease the risk of which complication?

Wernicke-Korsakoff syndrome

A client has been prescribed disulfiram (Antabuse). Before giving the client the first dose of this medication, what should the psychiatric home health nurse determine?

When the last alcoholic drink was consumed

A hospitalized client is receiving clozapine (Clozaril) for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study?

White blood cell (WBC) count

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client?

Writing

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse should prioritize that which symptoms or behaviors require immediate intervention?

constant physical activity and poor oral intake