Foundations and Practice of Mental Health Nursing HESI EXIT 2

What should a nurse recognize that a client who uses the defense mechanism of sublimation is doing?

Channeling unacceptable impulses into socially approved behavior

A nurse is teaching clients in a medication education group about side effects of medications. Which drug will cause a heightened skin reaction to sunlight?

Chlorpromazine

The parents of an autistic child begin family therapy with a nurse therapist. The father states that the family members wish to share their religious beliefs with the therapist. The nurse should:

Encourage family discussion of their religion in the sessions.

A client states, "The voices are saying I killed my husband." What is the best response by the nurse?

"You're having very frightening thoughts right now."

A depressed client is concerned about many fears that are upsetting and frightening and expresses a feeling of having committed the "unpardonable sin." What is the most therapeutic response by the nurse?

"Your thoughts are just a part of your illness, and they'll change as you get better.

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

Bupropion (Wellbutrin) has a unique side effect not shared by most other drugs of its class. The nurse should assess the client for which unique possible side effect of this drug?

Generalized seizures

A nurse assessing the behavior of the parents of a physically maltreated child expects that the parents will:

Give contradictory explanations of what happened.

A nurse notes that haloperidol (Haldol) is most effective for clients who exhibit behavior that is:

Overactive

Which relationship is of most concern to the nurse because of its importance in the formation of the personality?

Parent-child relationships

The parents of an adolescent who engages in self-injurious cutting behavior ask the nurse why their child self-mutilates. What should the nurse give as the reason for the cutting?

Way to manage overwhelming feelings

A young child in whom sexually abuse is suspected asks the nurse, "Did I do something bad?" What is the most therapeutic response by the nurse?

What do you mean by something bad?"

A client is admitted to the hospital because of incapacitating obsessive-compulsive behavior. The statement that best describes how clients with obsessive-compulsive behavior view this disorder is:

"I know there's no reason to do these things, but I can't help myself."

A young adult client is hospitalized with a spinal cord injury. The client, knowing that the paralysis may be permanent, says, "I wish God would end my suffering and take me." What is the most therapeutic initial response by the nurse?

Being incapacitated is difficult for you."

A client describes his delusions in minute detail to the nurse. How should the nurse respond?

By changing the topic to reality-based events

The husband of a woman who has been sexually assaulted arrives at the hospital after being called by the police. After reassuring him about his wife's condition, the nurse should give priority to:

Discussing with him his own feelings about the situation

A nurse is assessing a client who has been emotionally immobilized since her husband requested a divorce and moved out of their home. What should be determined first by the nurse in the crisis intervention center?

What the divorce means to the client

A client's hands are raw and bloody from a ritual involving frequent handwashing. Which defense mechanism does the nurse identify?

undoing

A practitioner prescribes haloperidol (Haldol) 10 mg by mouth twice a day for a client who is also receiving phenytoin (Dilantin) for control of epilepsy. When planning the client's care, the nurse considers that anticonvulsants may interact with haloperidol to:

Potentiate its central nervous system depressant effect.

A nurse is considering Erikson's stages of psychosocial development while caring for a client. Which behavior is consistent with a problem involving trust versus mistrust?

Woman whose parents were chronic alcoholics and who has problems making friends

After helping a neighborhood family through a crisis situation, an executive asks the nurse to come to his business to discuss with the employees the principles of maintaining mental health in today's world. What is the nurse's primary consideration before deciding the approach or content for the discussion?

Involving employees in the initial planning for the session

A client who is receiving haloperidol (Haldol), 5 mg three times a day, complains of twitching of the fingers. What is the best response by the nurse?

"I'll ask the doctor to prescribe a medication that'll help overcome this. It's a side effect of the drug you're taking."

A nurse is working with a married woman who has come to the emergency department several times with injuries that appear to be related to domestic violence. While talking with the nurse manager, the nurse expresses disgust that the woman keeps returns to the situation. What is the best response by the nurse manager?

"Most women try to leave about six times before they are successful."

During an assessment the nurse realizes that the client is experiencing a hallucination when the client says:

"My insides smell like they're going to just rot away."

A client with depression has not responded to a tricyclic antidepressant and outpatient electroconvulsive therapy (ECT). The health care provider prescribes selegiline (Eldepryl), and the nurse teaches the client about food to be avoided while taking this medication. Which foods identified by the client allow the nurse to conclude that the instructions have been understood? Select all that apply.

1. Aged cheese 2. Chocolate drinks

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.

1. Bipolar disease 2. Paranoid schizophrenia

Which client in a psychiatric unit needs immediate therapeutic intervention from the nurse?

A 50-year-old woman who is pacing back and forth across the dayroom and picking fights with other clients

A nurse working in a mental health clinic has a caseload composed of a number of individuals and families. Which members of the caseload are at the greatest risk for mental health problems?

A family with a new baby, a divorced man, a recently retired older woman

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

In conjunction with which classification of medication are trihexyphenidyl, biperiden (Akineton), and benztropine (Cogentin) often prescribed?

Antipsychotics

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.

Naltrexone (Depade) is used to treat clients with substance abuse problems. In which situation does the nurse anticipate that naltrexone will be administered?

Decrease the recovering alcoholic's desire to drink alcohol.

The nurse should first discuss terminating the nurse-client relationship with a client during the:

Orientation phase, when a contract is established

An executive assistant experiences an overwhelming impulse to count and arrange the rubber bands and paper clips in his desk. The client feels that something dreadful will occur if the ritual is not carried out. Considering the client's symptoms, the nurse concludes that rituals:

Serve to control anxiety resulting from unconscious impulses

A client with a history of a short temper and physically abusive behavior becomes violent and is admitted to the psychiatric service. At the time of admission the client is extremely anxious. What is the priority nursing action?

Assigning a staff member to supervise the client

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

When lithium therapy is instituted, the nurse should teach the client to maintain an adequate daily intake of:

Sodium

A nurse on a mental health unit administers a variety of antipsychotic medications. The nurse concludes that olanzapine (Zyprexa, Zydis) has a distinct advantage over other antipsychotics because:

Tablets disintegrate immediately in the mouth, preventing tablet "cheeking."

A newly admitted client looks at but does not respond to the nurse. What is the most appropriate statement by the nurse?

"I'm here to offer you my help and tell you about the services available to you on the mental health unit."

To help establish a therapeutic nurse-client relationship, the mental health nurse uses various communication techniques to convey a willingness to listen and a genuine desire to view the client and his or her needs in a respectful manner. What is the primary underlying principle guiding this process?

Caring is the underlying component of nursing that promotes client care.

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

Which activity is most appropriate for a nurse to introduce to a depressed client during the early part of hospitalization?

Project involving drawing

When used in combination with certain foods and drugs, monoamine oxidase inhibitors (MAOIs) can cause serious side effects. Which condition could occur in clients treated with MAOIs for depression?

A serious increase in blood pressure

With the client's permission, the nurse should inform the family about what is happening. The main reason for this action is that informed families:

Are better equipped to assist the client

During a group therapy session some members accuse another client of intellectualizing to avoid discussing feelings. The client asks whether the nurse agrees with the others. What is the best response by the nurse?

Are you uncomfortable with what you were told?"

A young adult being treated for substance abuse asks the nurse about methadone. The nurse responds that methadone is useful in the treatment of opioid addiction because it:

Has an effect of longer duration

What conflict associated with Erikson's psychosocial stages of development should the nurse remember when caring for a client 30 years of age?

Intimacy versus isolation,

What is an initial client objective in relation to anger management?

Taking responsibility for the hostile behavior

A nurse is creating a therapy group for low-functioning clients. Which client is the most appropriate member?

A 77-year-old man with anxiety and mild dementia

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

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

A client has been taking the prescribed dose of clozapine (Clozaril). The nurse should assess the client for which life-threatening side effect of this drug?

Agranulocytosis

A nurse is counseling a recently widowed client, who says, "His death has complicated my life even more than the hassles he caused when he was alive!" The nurse realizes the client is having difficulty with the grieving process and nurse concludes that the relationship with the husband was probably:

Ambivalent

Alprazolam (Xanax) is prescribed for a client with the diagnosis of panic disorder. The client refuses to take the medication because he fears addiction. Initially the nurse should:

Assess the client's feelings about alprazolam further.

A cognitively impaired older adult is brought to the emergency department for treatment of a cut on the forehead. Based on the following assessment information the nurse concludes that the individual's priority need is:

Assessment for possible physical abuse

A nurse in a long-term care facility is caring for a bedridden client with multiple chronic illnesses. Although usually continent, the client expresses anger through urinary incontinence. What should the nurse do to best address this situation?

Assist the client in setting realistic short-term goals.

An older man is widowed suddenly when his wife is killed in an automobile accident. What should the nurse in the emergency department do first to best help the client at this time?

Assure him that everything possible was done for his wife.

A nurse is performing a mental status assessment. What is being assessed when the nurse notes that the client is cooperative?

Attitude

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

A single mother of two children who recently lost her job because her company is downsizing comes to the emergency department. The woman does not know what to do and is in crisis. The most critical factor for the nurse to determine during crisis intervention is the client's:

Available situational supports

A nurse is aware that after the administration of alprazolam (Xanax) is started, it is important to assess the client for side effects. What is the nurse's initial action?

Check the client's blood pressure.

A nurse has just completed a mental status examination on a newly admitted psychiatric client and returns to the nurses' station to document the results. The nurse reflects on the client's drawn-out explanation of the reason for the admission and concludes that excessive detail was given before the client eventually answered the questions. What mental process does the nurse identify?

Circumstantiality

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)

When planning nursing care for clients who are grieving the potential death of a family member, it is helpful to draw on the understanding of the five stages of grieving identified and described by Elisabeth Kübler-Ross. Place these stages in order of progression from first to last.

Denial Anger Bargaining Depression Acceptance

A 34-year-old woman who was sexually assaulted is examined in the emergency department within 2 hours of the assault. During assessment she freely discusses the incident, her past psychiatric history, and her past sexual history with the sexual assault nurse examiner (SANE). Which information documented by the nurse indicates that the nurse needs more teaching about appropriate charting?

Details of the client's sexual history

When planning nursing care for a client with severe agoraphobia, the nurse should first:

Determine the client's degree of impairment.

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

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

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 nurse in a hospice program cares for clients and family members who are coping with imminent loss. What is the most important factor in predicting a person's potential reaction to grief?

Earlier experiences with grief

An older adult tells the nurse, "I regret so many of the choices I've made during my life." Which of Erikson's developmental conflicts has the client probably failed to accomplish?

Ego integrity versus despair

What treatment should a nurse anticipate will be prescribed for a client with severe, persistent, intractable depression and suicidal ideation?

Electroconvulsive therapy

It is most helpful to the nurse who is attempting to apply the principles of mental health to consider that:

Emotional health is promoted when there is a sense of mastery of self and the environment.

A client receiving risperidone (Risperdal) is going on an all-day fishing outing with family members. It is important that the nurse:

Encourage the client to use sunscreen.

Which client assessment does the nurse determine is inconsistent with the diagnosis of anorexia nervosa, restricting type?

Engages in episodes of purging

When managing the milieu, client autonomy and the need for therapeutic limit setting are concepts that often are in conflict. Which nursing intervention best minimizes this conflict?

Establishing unit rules that are appropriate and explained thoroughly

A nurse develops a relationship with a client who has bipolar disorder with episodes of mania. The nurse concludes that their therapeutic interaction has entered the working stage when the client:

Explores the effect of bipolar behavior on the family

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 arrives at the clinic and tells the nurse about various aches and pains since her spouse's death 3 months ago. The client appears depressed and tense. What is the initial nursing intervention?

Facilitating a discussion of the spouse's death

What type of an environment should the nurse provide for a confused client?

Familiar

A mental health nurse is participating in a therapy group. The nurse concludes that the group has reached the working stage when the members:

Focus on a variety of needs and concerns.

A nurse is caring for a terminally ill client who is considering signing an "allow natural death" (AND) document rather than the traditional do-not-resuscitate (DNR) order. In light of the process of grieving, what feeling associated with end-of-life decisions is the AND advance directive attempting to alleviate?

Guilt

An antianxiety medication is prescribed for an extremely anxious client. The client says, "I'm afraid to take these pills because I heard they're addictive." The nurse teaches the client that antianxiety medications:

Have the potential for physiological and psychological dependence

A nurse is caring for a 20-year-old client. According to Erikson's developmental psychosocial theory, what is expected by 20 years of age?

Having a coherent sense of self and plans for self-actualization

Which functions are registered nurses legally permitted to perform in a mental health hospital? Select all that apply.

Health promotion Case management Treating human responses

A client on the psychiatric unit sits alone most of the day. The nurse approaches the client. As the nurse gets approximately 3 feet away, the client lets out a string of profanity and shouts, "Leave me alone; I don't want to talk to you!" What is the most appropriate response by the nurse?

I'll leave for now, but I'll be back later."

A nurse may best assist abusing parents in altering their behavior toward their abused 2-year-old child by helping them:

Identify the specific ways in which the toddler's behavior provokes frustration.

According to Erikson, a young adult must accomplish the tasks associated with the stage known as:

Intimacy versus isolation

A client with a mood disorder is being discharged from a psychiatric hospital after agreeing to continue follow-up visits with a therapist. During the last interview with the nurse before discharge, the client says, "I've told you a lot about my life and my problems, but there are a few things that bother me that I've told no one." What is the most therapeutic response by the nurse once it has been determined that the client is not at risk for harming herself or others?

One purpose of continuing counseling is to allow you to discuss things that bother you.

A child has been hospitalized repeatedly for illnesses of unknown origin. Finally the health care provider makes the diagnosis of Munchausen syndrome by proxy. What is the most therapeutic approach by the nurse to the involved parent?

Open communication

A client is admitted with a bipolar disorder, depressed episode. The nursing history indicates a progressive increase in depression over the past month. What should the nurse expect the client to display?

Paucity of verbal expression related to slowed thought processes

A psychiatric unit uses a behavioral approach to determine a client's level of privileges. Which factor should a nurse use to determine whether an increase in privileges is warranted?

Performing hygiene activities independently

A nurse must consider a child's cognitive level of development when providing preoperative teaching. At which stage of Piaget's cognitive theory should the nurse anticipate that a child will experience the greatest fear of surgery?

Preoperational

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

A registered nurse (RN) in charge of a mental health unit has two additional staff members: a licensed practical nurse (LPN) and a nursing assistant (NA). The unit has 20 clients, with one client on constant observation for acute suicidality. What should the nurse in charge do when making the daily assignments?

Provide client care and administrative duties and assign the LPN to administer medications and the nursing assistant to maintain constant observation of the suicidal client.

A man is found to have paranoid schizophrenia, and the practitioner prescribes a typical antipsychotic medication. After taking the medication for 1 month the client comes to the clinic and says, "I feel stiff, my hands shake, and I started drooling." The picture illustrates the client's physical status observed by the nurse in the clinic. What extrapyramidal side effect does the nurse conclude has developed?

Pseudoparkinsonism

Which characteristic should the nurse predict will make an individual most likely to benefit from group therapy?

Recognizing that she has a problem

What assessment of a group member does the nurse use to identify the emotional-informal leader of the group?

Reflects the feeling tone of the group

A client sits huddled in a chair and leaves it only to assume the fetal position in a corner. The nurse, observing this, identifies the behavior as:

Regressive

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

A nurse expects that when an individual successfully completes the grieving process after the death of a significant other, the individual will be able to:

Remember the significant other realistically.

A nurse is caring for a group of clients on the psychiatric unit. What clinical findings should alert the nurse that serotonin syndrome has developed in one of the clients?

Restlessness, tachycardia, fever, diarrhea, and altered mental status

A nurse is interviewing a mother accused of physical child abuse. When speaking with this mother, the nurse expects her to:

Reveal the belief that her child needed to be disciplined.

The nurse notes that a young female client with anorexia nervosa telephones home just before each mealtime. She ignores reminders to eat and continues talking until the other clients are finished eating. She then refuses to eat food that has gotten cold. The nurse should initially:

Schedule a family meeting to discuss the problem.

An 8-year-old child with a terminal illness is demanding of the staff. The child asks for many privileges that other children on the unit do not have. The staff members know that the child does not have long to live. The nurse can best help the staff members cope with the child's demands by encouraging them to:

Set reasonable limits to help the child feel more secure and content.

A client with mental health problems is given a prescription for fluphenazine (Prolixin). The nurse develops a teaching plan about the medication. What should the nurse caution the client to avoid?

Staying in the sun

A hospice nurse is caring for a dying client while several family members are in the room. When the client dies, the initial nursing intervention during the shock phase of a grief reaction is focused on:

Staying with the individuals involved

A client on the psychiatric unit who has suicidal ideas says to the nurse, "I signed myself in. I'll sign myself out." What concept provides the basis for the nurse's response?

Suicidal clients may not sign out even if they voluntarily admitted themselves.

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 on the psychiatric service is pacing around the unit at a moderate rate and looking to either side of the hall. What is the most appropriate intervention by the nurse?

Talking with the client to assess the meaning of the behavior

While assessing an older adult in the emergency department the nurse notes that the client is upset. The nurse asks what is wrong, and the client describes the current situation and then offers information that goes further and further off the topic. What pattern of communication does this conversation reflect?

Tangential thinking

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.

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 female client undergoing presurgical testing before a possible colon resection and colostomy says to the nurse, "If I have to have this surgery, I know that my husband will never come near me again." What is the most therapeutic response by the nurse?

You're concerned about how your husband will respond to your surgery."

A client with schizophrenia is actively psychotic, and a new medication regimen is prescribed. A student nurse asks the primary nurse, "Which of the medications will be the most helpful against the psychotic signs and symptoms?" What response should the nurse give?

Ziprasidone (Geodon)

A client with mild Alzheimer disease has been taking galantamine (Razadyne), and the health care provider prescribes paroxetine (Paxil) for depression. For what effect should a nurse assess the client when these medications are taken concurrently?

additive

A nurse is performing discharge teaching for a client who has been receiving disulfiram (Antabuse). What statement indicates to the nurse that the client understands the teaching concerning disulfuram?

"I have to be careful to check over-the-counter medications."

The nurse tells a client that talking with the staff members is part of the therapy program. The client responds, "I don't see how talking to you can possibly help." What is the most appropriate response by the nurse?

"I hope I'll be able to help you sort out your thoughts and feelings so you can understand them better."

A practitioner plans to have a client with the diagnosis of bipolar disorder continue taking lithium after discharge. The nurse confirms that the teaching about the medication plan is understood when the client states:

"I know that I may need to take the medication for the rest of my life."

As depression begins to lift, a client is asked to join a small discussion group that meets every evening on the unit. The client is reluctant to join because, she says, "I have nothing to talk about." What is the best response by the nurse?

"You feel you won't be accepted unless you have something to say?"

An extremely depressed client signed the consent for electroconvulsive therapy (ECT) but continues to express anxiety about the procedure. What is most important for a nurse to emphasize when discussing ECT with the client?

"You won't be left alone during the procedure."

A client with schizophrenia has been experiencing hallucinations. During what client behaviors should the nurse expect the hallucinations to be more frequent?

Rest.

A client who is being discharged with severe facial scarring from burns tells the nurse, "I've saved some oxycodone, and when I get home I'm going to take all of them. Don't tell anyone." What is the best response by the nurse?

"Are you going to kill yourself?"

At a group therapy session a member, in a teasing manner, makes several negative remarks about the nurse's appearance and behavior. The nurse can best respond by saying to the:

Client, "You seem very interested in my appearance and behavior. What's this all about?"

The husband of a woman who gave birth to a baby 2 weeks ago calls the postpartum unit at the hospital, seeking assistance for his wife. He reports that he found his wife in bed and that the baby was wet, dirty, and crying in the crib. He says, "She says she just can't do it." What is the best response by the nurse?

Informing him that he should seek emergency intervention for his wife

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

An unmarried pregnant client who has been attending a crisis intervention clinic has decided to keep the baby and is looking forward to motherhood. The nurse identifies that the decision to attend prenatal childcare classes as an example of:

Intrinsic motivation

A depressed client is very resistive and complains about inabilities and worthlessness. The best nursing approach is to:

Involve the client in activities in which success can be ensured.

A nurse is conducting an assessment interview with a client who has lost a life partner. In light of the information elicited, the nurse suspects that the client:

Is experiencing dysfunctional grief

A nurse is caring for a client with the diagnosis of schizophrenia who is started on fluphenazine decanoate (Prolixin Decanoate). What is the primary advantage of this medication?

It has a long-lasting effect.

A primary nurse notes that a client has become jaundiced after 2 weeks of antipsychotic drug therapy. The nurse continues to administer the antipsychotic until the health care provider can be consulted. What does the nurse manager conclude about this situation?

Jaundice is sufficient reason to discontinue the antipsychotic.

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 an 11-month-old infant with failure to thrive are referred to the crisis intervention clinic. What is the primary crisis intervention that the nurse should use?

Problem-solving

The nurse can best handle personal questions asked by the client in any phase of the nurse-client relationship by:

Providing brief, truthful answers and redirecting the focus of conversation

A nurse believes that a client who is being discharged after a physical attack by an unknown assailant will benefit from further care to help resolve residual feelings. For what type of therapy should the nurse refer the client?

Short-term therapy emphasizing crisis intervention

A nurse is caring for several extremely depressed clients. The nurse determines that these clients seem to do best in settings where they have:

Simple daily routines

A nurse facilitating a support group of widows and widowers recalls that research indicates that the probability of a spouse having a pathological or morbid grief response will be greater if:

The cause of the spouse's death was suicide.

An adolescent with anorexia nervosa frequently telephones home just before mealtimes. The client uses the phone calls to avoid eating. What client behavior supports the nurse's conclusion that the nursing plan to set limits on this avoidance behavior has been effective?

The client arrives on time for meals without being told

Erik Erikson posited life as a sequence of achievements. Place the levels of development in their order of achievement according to Erikson's theory.

1. Industry versus inferiority 2. Identity versus role confusion 3. Intimacy versus isolation 4. Generativity versus stagnation 5. Integrity versus despair

The nurse and client have entered the working phase of a therapeutic relationship. What can the nurse expect the client to do during this phase? Select all that apply.

1. Initiate topics of discussion. 2. Accept limits on unacceptable behavior. 3. Express emotions related to transference

A nurse in the mental health clinic concludes that a client is using confabulation when:

Imagination is used to fill in memory gaps.

A child in the first grade is murdered, and counseling is planned for the other children in the school. What should a nurse identify first before assessing a child's response to a crisis?

Developmental level of the child

A nurse is educating a client with diabetes about insulin and appropriate nutritional intake. Which statement indicates that the client understands the teaching?

"I can eat lots of foods as long as I stick to my exchange units."

The parent of a child with a tentative diagnosis of attention deficit-hyperactivity disorder (ADHD) arrives at the pediatric clinic insisting on getting a prescription for medication that will control the child's behavior. What is best response by the nurse?

"It must be frustrating to deal with your child's behavior

During a nurse's interview with a client who has been sexually assaulted, the woman states that she should have fought back. What is the most therapeutic response by the nurse?

"It's hard to know, but what's important is that you're alive."

A 3-year-old child is brought to the emergency department by the mother, who reports that her child fell down the stairs and sustained injuries to the right arm and leg. During the physical assessment the nurse identifies a number of old bruises on the child's back, buttocks, and upper arms. What should the nurse say to the child to obtain additional information?

"Show me how you fell down the stairs."

During a phone conversation to a crisis hotline a client states, "I'm falling apart and can't put myself together. This goes on and on." What is the most therapeutic response by the nurse?

"What's happening right now that prompted you to call?"

A client with a prolonged history of chronic schizophrenia, paranoid type, shows the nurse a small plastic keychain and says that it provides protection from evil forces. The client then quickly hides the keychain, yelling, "Don't take it away from me; it's the only thing that protects me." The nurse should respond:

"You may keep it, because I know it's important to you."

A woman who is frequently physically abused tells the nurse in the emergency department that it is her fault that her husband beats her. What is the most therapeutic response by the nurse?

"You say that it was your fault—help me understand that."

A parent of four is remanded to the psychiatric unit by the court for observation. The client was arrested and charged with abusing a 2-year-old son, who is in the pediatric intensive care unit in critical condition. The nurse approaches the client for the first time. How should the nurse anticipate that the client will likely respond? Select all that apply.

1. By denying beating the son 2. By avoiding talking about the situation 3. By exhibiting an emotional response that is inconsistent with degree of injury

Which nursing activities are specifically focused on achieving Healthy People 2010's mental health objectives? Select all that apply.

1. Providing suicide screening for a senior citizens group 2. Initiating outpatient services for homeless schizophrenic adults 3. Teaching stress-management techniques to those housed in the local jail 4. Advocating for culturally competent mental health care within each state

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.

1/Focusing on the child's role in sustaining the injury 2/Changing the story of how the child sustained the injury 3/Giving an explanation of how the injury occurred that is not consistent with the injury

Which statements describe a mentally healthy person? Select all that apply.

1/One who accepts aging 2/One who engages available strengths 3/One who sustains positive relationships

A 15-year-old girl is brought to the high school health office by two of her friends, who report, "We think she just took a handful of pills." The adolescent appears alert and refuses to speak. The school nurse's initial response should be to:

Ask the adolescent whether she took any pills.

A terminally ill client repeatedly tells the nurse all the details of a daughter's wedding that will take place in 6 months and how important it is for her to attend. What Kübler-Ross stage of grieving does the nurse identify?

Bargaining

Before effectively responding to a sexually abused victim on the phone, it is essential that the nurse in the rape crisis center:

Be aware of any personal bias about sexual assault.

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

A nursing home resident with dementia of the Alzheimer type, stage 2, who has been receiving donepezil (Aricept) is engaging in numerous acting-out behaviors. On what should the nurse base the initial plan of care?

Identifying the stressors that precipitate the client's behavior

The nurse manager hears a conversation between a nurse and a client that is focused on the details of their impending divorces. What is the nurse manager's response?

Immediately asking to speak to the nurse privately and stating that sharing such personal information is nontherapeutic and not tolerated

A nurse is considering the family's role in discharge planning for an adult client who has been in a psychiatric facility. What is the most appropriate nursing action after the nurse obtains the client's consent?

Including the family when making specific discharge plans

A Latino client with schizophrenia is admitted to a mental health unit in an aggravated and disheveled state after failing to take prescribed medications for the last 5 days. While developing a plan of care that incorporates the client's cultural background, the nurse gives priority to:

Inclusion of the family in the plan of care with the client's permission

Which suicide method is the least lethal?

Ingesting pills

A newly admitted client quietly listens to a nurse's explanation of the services and activities available on the mental health unit. When the nurse is finished, the client looks around and says, "So this is where they keep the crazies." What is the most appropriate initial response by the nurse?

"Are you feeling that a person has to be crazy to need mental health services?"

A depressed client tells the nurse, "I don't get out of bed most mornings because I don't feel like it." What is the best reply by the nurse?

"Getting up and involved in an activity should help lift your mood."

A nurse who suspects that a newly admitted infant is the victim of child abuse assesses the parents' interaction with their baby. What parental behaviors might support the diagnosis of child abuse? Select all that apply.

1. Exhibiting difficulty in showing concern for their child 2. Procrastinating in obtaining treatment for their child's injuries

A nurse working in a crisis center understands that a crisis can best be defined as:

A threat to equilibrium

A female client with obsessive-compulsive disorder has become immobilized by her elaborate handwashing and walking rituals. The nurse recalls that the basis of obsessive-compulsive disorder is often feelings of:

Anxiety and guilt

A client is admitted to a mental health facility because of maladaptive coping behavior. How can the nurse best help the client develop healthier coping mechanisms?

By setting realistic limits on the client's maladaptive behavior

In an attempt to remain objective and support a client during a crisis, the nurse uses imagination and determination to project the self into the client's emotions. This technique is known as:

Empathy

A client is receiving doxepin (Sinequan). For which most dangerous side effect of tricyclic antidepressants should a nurse monitor the client?

Mydriasis

During a group discussion of the local news, a client asks how the nurse feels about the events in question. What is the best response by the nurse?

Providing a brief answer and redirecting the focus of the conversation

What should the nurse do when determining whether a client is experiencing adverse effects of risperidone (Risperdal)?

Question if dizziness is experienced

Why should the nurse question a prescription for a benzodiazepine for an individual experiencing acute grief?

The period of denial is extended and the grieving process is suppressed.

A client has been taking escitalopram (Lexapro) for treatment of a major depressive episode. On the fifth day of therapy the client refuses the medication, stating, "It doesn't help, so what's the use of taking it?" What is the best response by the nurse?

"It can take 1 to 4 weeks to see an improvement."

A newly immigrated older Chinese adult is brought to a mental health clinic when family members become concerned that their parent is depressed. In an attempt to conduct a culturally competent assessment interview, the nurse asks certain questions. Select all that apply.

1. "What brought you here for treatment today?" 2. "What do you believe is the cause of your depression?" 3. "Does religion have a role in your perception of health and wellness?" 4. Have you ever sought treatment for a mental health problem previously?"

A nurse provides crisis intervention for a client who recently left her husband because of physical abuse. Which client behaviors indicate to the nurse that the therapy has been successful? Select all that apply.

1. Utilizes healthier coping skills 2. Describes the current situation realistically

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.

1/Verbalizes difficulty identifying personal strengths 2/Acknowledges the effects of the addiction on the family 3/Addresses how the addiction has contributed to family distress

As a client addicted to cocaine withdraws from the drug, the nurse should expect to observe behavior related to:

Depression

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.

A client who has just experienced her second spontaneous abortion expresses anger toward the practitioner, the hospital, and the "rotten nursing care." When assessing the situation, the nurse concludes that the client may be using the coping mechanism of:

Displacement

A nurse greets a client who has been experiencing delusions of persecution and auditory hallucinations by saying, "Good evening. How are you?" The client, who has been referring to himself as "the man," answers, "The man is bad." Of what is this an example?

Dissociation

A female client is admitted to the acute care psychiatric unit with a diagnosis of panic disorder with agoraphobia. During the initial assessment phase the nurse should focus on:

Easing the client's anxiety so further interviewing may be done

A 25-year-old man is admitted to the inpatient psychiatric unit. He is angry and refuses to take his prescribed medications at bedtime. He has been agitated and had several verbal altercations with other clients earlier in the evening. The best nursing response to this situation is:

Educating him on the reasons for and benefits of taking the medication but not giving it to him if he continues to refuse the medication

An older retired client is visiting the clinic for a regularly scheduled checkup. The client tells the nurse about the great life he has lived and the activities that he enjoys at the senior center. According to Erikson, what developmental conflict has been resolved by this client?

Integrity versus despair

A nurse recalls that the focus of environmental (milieu) therapy is to:

Manipulate the client's environment to bring about positive changes in behavior.

A young mother of three children, all born 1 year apart, has been hospitalized after trying to hang herself. The client is being treated with milieu therapy. The nurse understands that this therapeutic modality consists of:

Manipulating the environment to benefit the client

A client is admitted to a psychiatric hospital because of a recurrent mental health problem. During admission the nurse determines the expected client outcomes. The nurse concludes that these outcomes are:

Measurable objectives

The staff of a mental health unit is conducting an orientation meeting for newly admitted clients. What should the nurse plan to address first at the meeting?

Purpose of the group meeting

What should a nurse ensure when creating an environment that is conducive to psychological safety?

Realistic limits are set.

A health care provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior. What is the nurse's responsibility in regard to this order?

Recognizing that PRN orders for restraints are unacceptable

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 both mean the same thing." This is an example of the technique of:

Seeking consensual validation

A high school student reports to the school health nurse that the prescribed antidepressant is no longer needed and should be discontinued. What is the best response by the nurse?

Seeking further information

What is most important for a nurse to do when initially helping clients resolve a crisis situation?

Support coping behaviors

A nurse educator is leading a class on supporting middle-aged adults who are experiencing midlife crises. What should the nurse include as the most significant factor in the development of this type of crisis?

The perception of their life situation

On which generally accepted concept of personality development should a nurse base care?

The personality is capable of being modified throughout life.

What is the most important tool a nurse brings to the therapeutic nurse-client relationship?

The self and a desire to help

A client with an antisocial personality disorder is being admitted to a mental health unit. What information should the nurse include in this initial interview?

The unit's usual routines and rules

A nurse is caring for several clients who have severe psychiatric disorders. What is the major reason that a health care provider prescribes an antipsychotic medication for these clients?

To reduce the positive symptoms of psychosis

A client with a diagnosis of major depression tells a nurse, "No matter what I do, everything turns out bad." The nurse recognizes this as an example of:

Using a cognitive distortion

When a client enters the emergency department in a psychiatric emergency, the nurse should perform an assessment in an organized manner. Place the following interventions in their order of priority, beginning with number 1 as the highest priority.

1. Collect identifying information. 2. Obtain the chief complaint. 3. Identify presenting clinical findings. 4. Explore the previous psychosocial history. 5. Document collected information on the clinical record.

A nurse teaches a client about the side effects and precautions associated with the antipsychotic haloperidol (Haldol). The nurse concludes that the teaching has been understood when the client states:

"I'll avoid direct sunlight and make sure to use sunscreen when I go outside."

Windows in the recreation room of the adolescent psychiatric unit have been broken on numerous occasions. After a group discussion one of the adolescents confides that another adolescent client broke them. What should the nurse do when using an assertive intervention instead of aggressive confrontation?

Approach the adolescent when he is alone and, after making direct eye contact, inquire about his involvement in these incident

A confused, acting-out client is brought to the psychiatric emergency service by the police. During admission the client refuses to let the nurse touch a bag that she is carrying. What is the most appropriate approach for the nurse to learn the contents of the bag?

Asking the client to open the bag while describing the contents

When talking with a client in crisis, the crisis intervention nurse should first:

Assist the client in deciding what will be done and how it will be done.

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

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

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 client with emotional problems is being discharged from a psychiatric unit. What should the nurse encourage the client to do?

Enroll in an aftercare program.

A client with schizophrenia is demonstrating waxy flexibility. Which intervention is the best way to manage the possible outcome of this behavior?

Passive range-of-motion exercises three times a day for effective joint health

At 4 am on a Saturday a client calls the crisis hotline. On what should the nurse focus during the initial assessment?

Perception of the crisis event

A confused hallucinating client says, "My arms are turning to stone." What is the most therapeutic response by the nurse?

"It can be frightening to feel that way."

A female client in the terminal stage of cancer is admitted to the hospital in severe pain. The client refuses the prescribed intramuscular analgesic for pain because it puts her to sleep and she wants to be awake. One day, despite the client's objection, a nurse administers the pain medication saying, "You know that this will make you more comfortable." The nurse in this situation could be charged with:

Battery.

A young adult client with schizophrenia is prescribed haloperidol (Haldol). When the nurse administers the medication, the client asks, "What's this for?" The nurse responds that the medication:

Will help him relax and think more clearly

A client who has schizophrenia is receiving a phenothiazine antipsychotic medication. Which serious client responses to the medication should the nurse immediately report to the practitioner? Select all that apply.

Yellow sclerae Involuntary tongue movements

An older adult with a diagnosis of delirium on the mental health unit begins acting out while in the dayroom. What is the initial nursing intervention?

Giving the client one simple direction at a time in a firm low-pitched voice

A nurse begins terminating the consistent one-to-one relationship with a client who is soon to be discharged. How might the nurse expect the client to respond to the termination of their relationship?

Grief

During a nurse-client interaction in the mental health clinic, a client states that there has been a lot of "stress relation" lately. What does the nurse conclude that this statement reflects?

Neologism

A widow of 6 months is brought to a psychiatric hospital. During the assessment interview the client avoids eye contact, responds in a low voice, and is tearful. What is the best initial approach by the nurse?

"I know that this is difficult, but as soon as we're finished I'll take you to your room."

Donepezil (Aricept) is prescribed for a senior client who has mild dementia of the Alzheimer type. What information does the nurse include when discussing this medication with the client and family?

Blood tests that reflect liver function will be performed routinely.

A client on the psychiatric unit who is receiving high-dosage risperidone (Risperdal) is exhibiting tremors of the hands. What should be the nurse's first intervention?

Contacting the health care provider

When leading the first session of a newly formed group of clients in a mental health clinic, the nurse notes that group members frequently assume self-serving roles. The nurse understands that:

Early group development involves these behaviors.

When the pediatric nurse practitioner examines the genital area of a 5-year-old child in whom sexual abuse is suspected, the most therapeutic action by the primary nurse is:

Explaining the procedure and remaining with the child during the examination

The following data is recorded during the assessment of a client being treated in the emergency department for minor injuries resulting from a mugging and robbery. In light of this information, the nurse initially:

Explains that feeling anxious is a common response to such an experience

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 client is to begin lithium carbonate therapy. The nurse should ensure that before the drug's administration the client has baseline:

Renal studies

As a young male client is undergoing a dialysis treatment, the nurse notes that he is not talking with the other clients and that his eyes are lowered and his jaw clenched. The nurse says, "You look discouraged." The client replies, "I'm a bother. My wife would at least get some insurance money if I died." Which is the most therapeutic response by the nurse?

You feel so bad you wish you were dead."

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 intramuscularly,,

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.

A nurse in a mental health unit of the emergency department of a hospital frequently cares for adolescents who attempt suicide. What is important for the nurse to remember about adolescent suicide behavior?

Boys are more likely to use lethal methods than are girls

A friend asks a student nurse whether there is a drug marketed for smoking cessation. The student nurse researches a drug textbook to find the answer to this question. What antidepressant drug does the student nurse learn is available for this clinical application?

Bupropion (Zyban)

A client who has recently become blind as a result of an injury responds to the loss of autonomy by being sarcastic. How can the nurse best respond to this behavior?

By accepting the behavior

A nurse is orienting a new client to the unit when another client rushes down the hallway and asks the nurse to sit down to talk. The client requesting the nurse's attention is manipulative and uses acting-out behaviors when demands go unmet. How should the nurse intervene?

By saying to the interrupting client, "I'll be back to talk with you after I orient this new client."

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 nurse approaches a depressed client who has just been admitted to the psychiatric unit and says, "Hello! I'm Andrea, your nurse. I'll introduce you and help you settle in with the others here. We'll also talk about anything that concerns you." These statements establish the nurse-client relationship by:

Defining boundaries

A client has had repeated hospitalizations for aggressive, violent behavior. While on the mental health service, the client becomes very angry, starts screaming at the nurse, and pounds the table. What is the priority nursing assessment at this time?

Degree of control over the behavior

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

Fourteen months after the traumatic death of a spouse, a client comes to the mental health clinic complaining of continuing depression and states, "I haven't been seeing any of my friends or attending any of the activities I previously enjoyed. My children are married and live in another state, and I almost never see them." What does the nurse determine that the client is experiencing?

Difficulty grieving

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

What medication should the nurse expect to administer to actively reverse the overdose sedative effects of benzodiazepines?

Flumazenil

The nurse explores the possibility of joining Narcotics Anonymous (NA) with a client who has a history of drug abuse. What is a major reason that NA is helpful in treating addictive behavior?

Group members are supportive of one another's problems.

A mother whose daughter has been killed in a school bus accident tells the nurse that her daughter was just getting over the chickenpox and did not want to go to school but she insisted that the girl go. The mother cries bitterly and says that her child's death is her fault. The nurse understands that perceiving a death as preventable most often will influence the grieving process in that it may:

Grow in intensity and duration

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

What statement by a 45-year-old woman scheduled for an abdominal hysterectomy and bilateral salpingo-oophorectomy should alert the nurse to the potential for postoperative coping difficulties?

I'm not the least bit worried."

An adult who has been in a gay relationship for 3 years arrives at the emergency department in a state of near-panic. The client says, "My partner just left me. I'm a wreck." What should the nurse do to help the client cope with this loss? Select all that apply.

Identify the client's support systems. Encourage the client to talk about the situation.

After determining that the nurses on the psychiatric unit are uncomfortable caring for clients who are from different cultures than their own, the nurse manager establishes a unit goal that by the next annual review there will be:

Increased cultural competence

A nurse recalls that the blockage of dopamine by antipsychotic drugs can cause extrapyramidal side effects such as akathisia. Which client behaviors reflect the presence of akathisia?

Motor restlessness, foot tapping, and pacing

A health care provider prescribes carbamazepine (Tegretol) for a client. The nurse teaches the client about effects of the drug that should be reported to the health care provider. Which effects identified by the client as cause to call the provider indicate an understanding of the teaching? Select all that apply.

Nausea or vomiting Unusual bleeding or bruising

A client tells the nurse in the mental health clinic that the practitioner said that the cornerstone of therapy used in the clinic is cognitive therapy. The client asks what this therapy entails. What concept should the nurse explain as the basis of cognitive therapy?

Negative thoughts can precipitate anxiety."

A client with schizophrenia is speaking made-up words that have no meaning to other people. What term should the nurse use to document these verbalizations?

Neologisms

A client tells a mental health nurse about hearing a man speaking from the corner of the room. The client asks whether the nurse hears him, too. What is the nurse's best response?

No, I don't hear him, but it probably upsets you to hear him."

During a therapy group session, a female client begins to cry and tells the other group members that her husband has told her that he wants a divorce. What is the most appropriate initial response by the nurse?

Observing how the group responds to her statement

A group of clients from a psychiatric unit, accompanied by staff members, are going to a professional baseball game. The purpose of visits into the community under the supervision of staff members is:

Observing the clients' abilities to cope with a more complex society

A nurse is counseling a client who is experiencing substance abuse delirium. What communication strategies should be used by the nurse when working with this client?

Offering an introduction to the client at each meeting

Antipsychotic drugs can cause extrapyramidal side effects. Which responses should the nurse document as indicating pseudoparkinsonism? Select all that apply.

Rigidity Tremors Bradykinesia

A health care provider prescribes antipsychotic medication, and the nurse teaches the client about the possible side effects of the drug. The nurse concludes that the client needs further teaching about these side effects when he states that he should call the clinic if he experiences:

Ringing in the ears

A client with a family history of diabetes is concerned about the effects of psychiatric medication on the endocrine system. Which psychotropic medication is most likely to cause metabolic syndrome?

Risperidone (Risperdal)

According to Erikson, what will happen to an individual who fails to master the maturational crisis of adolescence?

Role confusion

The nurse is caring for an Asian-American client with a diagnosis of depression. While interviewing this client the nurse notes that the client maintains traditional cultural beliefs and values. What is the most important information for the nurse to obtain about the client?

Role within the family

Olanzapine (Zyprexa) is prescribed for a client with bipolar disorder, manic episode. What cautionary advice should the nurse give the client?

Sit up slowly.

The nurse finds a disturbed, acting-out male client in the fetal position. What is the most appropriate intervention for the nurse?

Sitting down beside him 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."

A nurse is teaching a group of recently hired staff members about defense mechanisms. An example given is Scarlett O'Hara, in the movie Gone with the Wind, who said, "I'll think about that tomorrow." What defense mechanism does this statement reflect?

Suppression

A client with the diagnosis of schizophrenia is given one of the antipsychotic drugs. The nurse understands that antipsychotic drugs can cause extrapyramidal side effects. Which effect is cause for the greatest concern?

Tardive dyskinesia

In which situation is the use of seclusion contraindicated?

The client has expressed severe suicidal thoughts.

A client who is a regular user of cocaine is admitted to a rehabilitation facility. Which common side effects of regular cocaine use should the nurse expect when assessing this client?

Anxiety, dysphoria, and extreme suspicion

A hospitalized 7-year-old boy wakes up crying because he has wet his bed. It is most appropriate for the nurse to:

Change the child's bed while he changes his pajamas

When a newly admitted client with paranoid ideation tells the nurse about people coming through the doors to commit murder, the nurse should:

Listen to what the client is saying.

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 nurse is admitting a client to the unit. What interaction demonstrates effective therapeutic communication principles?

Maintaining a distance of at least 3 feet from the client

A nurse is evaluating the medication regimens of clients to determine whether the therapeutic levels have been achieved. For which medication should the nurse review the client's serum blood level?

Valproic acid (Depakene)

The laboratory calls to report that a hospitalized client's lithium level is 1.9 mEq/L after 10 days of lithium therapy. How should the nurse respond to this information?

By notifying the practitioner of the findings because the level is dangerously high

A client becomes angry and threatens another client. What is the nurse's most therapeutic intervention?

Encouraging the client to talk about why he or she became angry and then aggressive

A client with a history of obsessive-compulsive behaviors has a marked decrease in symptoms and expresses a wish to obtain a part-time job. On the day of a job interview the client arrives at the mental health center with signs of anxiety. What is the most therapeutic response to the client's behavior by the nurse?

"Going for your interview triggered some feelings in you. Perhaps you could call a friend to drive you there."

A nurse is teaching a client who is ready to be discharged from a health care facility. What is most important for the nurse to emphasize?

Continuing in an aftercare clinic

At a staff meeting, while discussing the return of one of the staff nurses from a drug rehabilitation program, one nurse states, "I don't know why we are wasting time on this. We all know that addicts go back to using drugs as soon as the pressure increases." What is the nurse manager's best response?

"It's important for us to share our feelings about staff members with problems."

Neuroleptic malignant syndrome develops in a client who is taking a conventional antipsychotic medication . What signs and symptoms does the nurse expect? Select all that apply.

1. Hyperpyrexia 2. Increased muscle tone 3. Respiratory depression

A nurse is aware that an older adult is at risk for social isolation as a result of certain factors. Select all that apply.

1. Living alone since a spouse's death 3 years ago 2. Experiencing progressive macular degeneration

A small fire has been set in the dayroom garbage can by a client who is currently demonstrating manic behavior. Place the following nursing interventions in the appropriate order to best ensure client and milieu safety.

1. Move all clients to a safe, controlled area. 2. Activate the unit's fire alarm system. 3. Place the manic client in a quiet environment with low stimulation. 4. Administer appropriate medications as prescribed if indicated.

A young woman is brought to the emergency department by friends after being sexually assaulted. The client has a small but deep laceration on her chin, as well as contusions on her arms and legs. The client appears withdrawn but calm. Place the following nursing interventions in the appropriate order to best address the client's immediate needs.

1. Talk to her in a calm, nonjudgmental manner. 2. Provide her with clear, concise explanations of care that will be provided. 3. Provide care for her laceration and contusions. 4. Encourage her to express her feelings concerning the assault. 5. Advise her of the potential related health risks and the treatments that are available.

A client with a history of chronic alcoholism was admitted to a surgical unit after surgery to repair a severely fractured right ankle. The nurse is concerned that the client is experiencing manifestations of acute alcohol withdrawal when certain documentation and assessment data from the last 6 hours seem to indicate this problem. Select all that apply.

1/Tremors in both hands make it difficult for the client to hold a cup. 2/The client's bed linens and pajamas had to be changed during the night as a result of increased diaphoresis. 3/The usually cooperative client becomes verbally abusive when asked to lower the volume of the television.

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 accompanying a client with a diagnosis of anxiety disorder who is pacing the halls and crying. When the client's pacing and crying worsen, the nurse suddenly feels uncomfortable and experiences a strong desire to leave. What is the most likely reason for what the nurse is experiencing?

An empathic communication of anxiety

The biggest problem for an older female client, immediately after the sudden death of her husband, will probably be her inability to cope with:

Anger

A client has been placed in seclusion as a result of uncontrolled physical aggression directed toward both the staff and another client. In light of the events set forth in the documentation, the nurse manager will initially:

Ask for details regarding how the staff attempted to manage the client before seclusion was initiated.

A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps client:

Become aware of their personal values.

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 for their scheduled meetings

A client has recently started taking a new neuroleptic drug, and the nurse notes extrapyramidal effects. Which drug does the nurse anticipate will be prescribed to limit these side effects?

Benztropine mesylate (Cogentin)

After 3 weeks of mental health therapy a client tells the nurse, "I feel ready to go home." How can the nurse best evaluate the client's readiness for discharge?

By asking the client to identify specific behaviors as examples of wellness

At a therapy group session a client tearfully tells the other members about being fired during the past week. How should the nurse respond?

By quietly observing how the group members respond to the client's news

The mental health nurse is facilitating a therapy group. How can the nurse further develop trust among the members of the group?

By reminding group members about the need for confidentiality within the group

A nurse overhears a client in a mental health hospital talking on the unit telephone. The conversation concerns a "fix" to be brought to the unit during visiting hours. The nurse knows that the client, who has a history of drug use, has a contract with the practitioner promising not to use street drugs while being treated in the inpatient unit. What is the best nursing intervention?

Calling an immediate staff meeting to share the information and develop a plan for intervention

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 staff member tells a nurse that an older client becomes irritable when asked to assist with activities of daily living. On what general information about older adults should the nurse base a response?

Decreased ability to cope

A hospice nurse is caring for a dying client and his wife. What factor will be a major determinant in the mourning outcome for the wife?

Importance of the deceased person as a source of support

A client who is to be discharged from an inpatient mental health facility is referred to a mental health daycare center in the community. What should the nurse identify as the primary reason for this referral?

Maintaining gains achieved during hospitalization

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.

An adolescent is brought to the emergency department by her parents because she says her heart is racing and she cannot catch her breath. The health care provider rules out heart and lung problems. What should the nurse do after obtaining interviewing the client and obtaining vital signs?

Remain with the client until the symptoms subside to provide support.

A client with schizophrenia is given an antipsychotic drug. The nurse recalls that of all the extrapyramidal effects associated with this type of medication, the one that requires discontinuation of the drug is:

Tardive dyskinesia

What is the planned effect of naloxone when it is administered for a heroin overdose?

To compete with opioids for receptors that control respiration

Which individual is coping with issues concerning dependence versus independence?

Toddler