Mental Health - Archer Review (2/2)

Choice B is correct. Under specific state and/or federal laws, nurses are mandated reporters, required to report any suspicion of child or elder abuse. Additionally, depending on the applicable jurisdiction, state law may mandate the nurse to report gunshot injuries, dog bites, specific criminal acts (i.e., rape, etc.), and certain infectious diseases (i.e., HIV, tuberculosis, monkeypox, etc.). The nurse should explain to the client that applicable state and/or federal law(s) require the nurse to report the suspected abuse to a specific entity or authority as outlined in the applicable law.

A 78-year-old woman is brought to the emergency department (ED) for evaluation of an arm injury. During the assessment, the nurse notices contusions in varying stages of healing covering the client's chest and legs. When the nurse asks how the bruises were sustained, the client reluctantly states that her son frequently hits her "if supper is not ready when he gets home from work." Which of the following is the most appropriate nursing response? A. "Oh? Let me talk to your son." B. "I appreciate your honesty, but I need to inform you that I am a mandated reporter, and I am required to report this." C. "Let's talk about how you can manage your time to prevent your son from getting upset." D. "Do you have friends who can help you or keep you safe until you resolve these important issues with your son?"

Choice A is correct. Once the client is at risk of harming himself, other clients, or staff, the nurse should call for help and prepare to administer a sedative/tranquilizer to calm him down. De-escalation should be continued all the time, talking, reassuring, and negotiating. However, physical intervention should be undertaken quickly for this mentally unstable client. Physical restraint should be the minimum necessary for the shortest period. Control is best done seated on a bed or kneeling, then restrained supine, not prone. Physical restraint should be accompanied by rapid sedation with medications.

A client in the psychiatric unit is having fits of uncontrolled anger. He is also seen shouting at staff and threatening to hurt them. The psychiatric nurse's most appropriate action would be: A. Call security to restrain and then sedate the client. B. Tell the client to calm down. C. Threaten the client to remove his privileges if he does not stop. D. Observe the client and leave him alone to calm down.

Choice C is correct. Here, the nurse uses an open-ended question to provide the client with an opportunity to elaborate further on the client's previous statement and provide the nurse with a baseline understanding of the client's knowledge and readiness for the surgery. By ascertaining this information, the nurse can determine the client's current knowledge level and identify relevant educational needs. Here, open-ended questions are the most therapeutic communication technique in this situation as these questions facilitate further discussion.

A client scheduled for hip replacement surgery expresses anxiety to the nurse regarding the upcoming surgery. Which response by the nurse is most therapeutic? A. "Everyone is nervous before any surgery. What you feel is completely normal." B. "Here's what's going to happen to you during the procedure. I will explain it to you in detail." C. "Can you tell me what you have been told about the surgery?" D. "Let me tell you about the care you will receive and the pain you should anticipate after the surgery."

"Are you having any thoughts of harming yourself?"

Based on these findings, it would be essential for the nurse to make which statement? - "Would you tell me more about your bedtime routine?" - "Could you describe the severity and quality of your pain?" - "Are you having any thoughts of harming yourself?" - "Have you ever received mental health services before?"

- The client was alert and oriented. - He described his mood as good and had a cheerful affect. - He denied any suicidal ideations. - The client stated he would be staying with friends from church. - He also stated that he found an outpatient therapist.

Click to highlight the findings in the progress note that specify that the client is ready for discharge Progress Note The client was alert and oriented. He described his mood as good and had a cheerful affect. He denied any suicidal ideations. The client stated he still isn't sleeping well and would like a prescription for a sleep aid. The client has not attended group therapy since admission. The client stated he would be staying with friends from church. He also stated that he found an outpatient therapist.

Choice A is correct. The orientation phase is characterized by the nurse and the client becoming familiar with each other. Establishing goals that are reasonable and important to the client is a classic component of the orientation phase.

The nurse assists the client in developing goals while hospitalized. This phase of the nurse-client relationship is best described as which of the following? A. Orientation phase B. Working phase C. Termination phase D. Pre-interaction phase

Choices C, D, and E are correct. These manifestations are consistent with physical abuse. Physical abuse is when an individual deliberately causes a child pain and/or injury. The degree of physical abuse can be minor to severe. Scalded burn injuries, bruising without a plausible explanation, and spiral fractures without sports injuries are consistent with physical abuse.

The nurse discusses the signs and symptoms of child abuse at an interprofessional conference. It would be correct for the nurse to identify which manifestations are associated with physical abuse? Select all that apply - Verbal assault - Sexual contact between legal parent/guardian - Spiral fractures without any sports injury - Scalded burns on legs - Bruises without plausible explanation

Choices A, C, and D are correct. Moderate anxiety is characterized by a client experiencing - Narrowing of the perceptual field Slightly scattered thought process The client can problem-solve and learn, although not at an optimal level Somatic symptoms such as headache, urinary urgency, and muscle tension Sympathetic symptoms such as an increased pulse, respiratory rate, palpitations, voice tremors, and shaking

The nurse in the mental health unit is assessing a client with moderate anxiety. The nurse would anticipate which signs and symptoms to support this finding? Select all that apply. increased pulse feeling of impending doom reports of headache narrowing of the perceptual field inability to problem-solve or learn hyperventilation

Choice B is correct. Modafinil is a psychostimulant that is effective in treating narcolepsy. This medication promotes wakefulness and is dosed either once or twice a day.

The nurse is caring for a client with narcolepsy. Which of the following medications would the nurse anticipate the primary healthcare provider (PHCP) prescribe? A. Aripiprazole B. Modafinil C. Ropinirole D. Quetiapine

Choices B, D, and E are correct. Depending on the inhalant, an individual may experience a loss of inhibition, headache, nausea, poor muscle coordination, and slurred speech. Alcohol may cause drowsiness, loss of inhibition, and difficulty walking. Marijuana may cause a slowed reaction time, difficulty with learning and memory, and hallucinations.

The nurse is educating community members on the signs and symptoms of substance abuse intoxication. Which information should the nurse include? Select all that apply. - Cocaine may cause increased pulse, low blood pressure, and paranoia. - Inhalants may cause slurred speech, loss of motor coordination, and nausea. - Heroin may cause increased alertness, paranoia, and increased respirations. - Alcohol may cause drowsiness, slurred speech, and difficulty with walking. - Marijuana may cause a slowed reaction time and problems with balance and memory.

Choices B, C, and D are correct. ECT is a safe therapy that induces seizures theorized to release monoamines, which may assist in treating psychiatric illnesses such as major depressive disorder and significant psychosis. Clients do not receive contrast dye ( Choice B) for this procedure; instead, this procedure involves no imaging and requires general anesthesia. Driving home after the procedure is prohibited because of the post-procedural confusion from general anesthesia and the ECT procedure itself ( Choice C). Clients may experience remission after several treatments, but one treatment is highly unlikely to bring remission ( Choice D). Instead, one session of ECT may bring some symptom improvement

The nurse is instructing a client who is scheduled for electroconvulsive therapy (ECT). Which of the following statements by the client would require follow-up? Select all that apply. - "I can take my morning antidepressant with a sip of water." - "I may feel a flushing sensation as the contrast dye is given." - "I should be able to drive home after this procedure." - "I will need one treatment for my depression to go into remission." - "I may experience some confusion after this procedure."

Choice A is correct. Asking the client whether they have guilt regarding their alcohol intake is part of the CAGE questionnaire. This is a standard questionnaire used to determine if alcohol dependence may be an issue. At times an individual may experience guilt associated with their alcohol intake.

The nurse is interviewing a client with a suspected alcohol-use disorder. Which question would be the most helpful in determining if the client may have this disorder? A. "Do you ever feel guilty about your drinking?" B. "Do you drink wine, liquor, or beer?" C. "Do you drink with friends and family?" D. "What age did you start consuming alcohol?"

Choice A is correct. Spirituality and religion are not synonymous. Spirituality refers to an interpretation of the client's beliefs regarding their own would or spirit and a connection bigger than oneself. Spirituality is fluid and often evolves. Religion is structured and may have a specific God or gods. Religion is often ritualistic and may involve readings from a well-regarded book or text. Spirituality is fluid and is purely internal to one's ability to feel connected and look inside for hope and strength. Religion often looks to an external source, such as the Bible, for guidance. This question is appropriate to ask the client to inquire about their spirituality.

The nurse is performing an assessment on a client newly admitted to the medical-surgical unit. Which question would be appropriate for the nurse to ask when assessing the client's spirituality? A. "What are your sources of hope and strength?" B. "Have you considered arranging a visit from members of your church?" C. "Do you attend worship any specific day of the week?" D. "Can you tell me about your dietary preferences and any restrictions?"

Choices A and D are correct. Severe impairments in functioning characterize borderline personality disorder. Its major features are marked instability, impulsivity, identity or self-image distortions, unstable mood, and unstable interpersonal relationships. Splitting is a hallmark manifestation of this disorder in which an inability to view both positive and negative aspects of others as part of a whole, results in viewing someone as either a wonderful person or a horrible person. Projection is also a cardinal defense mechanism for this disorder in which an individual unconsciously rejects emotionally unacceptable features and attributes them to others.

The nurse is planning care for a client with a borderline personality disorder. The nurse recognizes that the client will likely demonstrate which defense mechanism? Select all that apply. Splitting Sublimation Altruism Projection Conversion

Choices A, D, and E are correct. The antidote for opioid toxicity is naloxone which may be given IV, IM, Intranasal, or SubQ. Magnesium toxicity is treated with calcium gluconate. Flumazenil is indicated for benzodiazepine toxicity.

The nurse is teaching a group of students about drug toxicity. The nurse is correct in stating which of the following? Select all that apply. "Naloxone is the treatment for opioid toxicity." "Magnesium is the treatment for lead toxicity." "N-acetylcysteine is the treatment for naproxen toxicity." "Calcium gluconate is the treatment for magnesium toxicity." "Flumazenil is the treatment for benzodiazepine toxicity."

- Feelings of hopelessness - Feelings of loneliness - Recent death of his wife - Sleep disturbances

Which four (4) assessment findings require further investigation by the nurse? Feelings of hopelessness Worsening osteoarthritis Only attending church services Feelings of loneliness Recent death of his wife Sleep disturbances

Choice A is correct. Based on Kubler-Ross' stages of death and dying, this statement indicates the client is currently in the bargaining stage. Clients in this stage often attempt to buy time for some future event or occasion.

You are caring for a client at the end of life with a terminal disease. You overhear this client saying, "Lord, just give me two more months so I can go to my grandson's wedding." What is this client demonstrating with these words? A. Bargaining B. Depression C. Anger D. Denial

Choice D is correct. Post-traumatic stress disorder (PTSD) is characterized by ongoing and unyielding nightmares, flashbacks to a previous event, and intrusive, threatening thoughts. Post-traumatic stress disorder occurs primarily among those who have witnessed and/or been exposed to a severe traumatic event (i.e., warfare, rape, witnessing a murder, etc.) likely to invoke feelings of fear, helplessness, or horror in the individual who witnesses the event.

Your client is affected by nightmares, flashbacks to a previous event, and intrusive, threatening thoughts. Which disorder is this client most likely experiencing? A. Panic disorder B. A phobia C. Anxiety disorder(s) D. Post-traumatic stress disorder

Choices A, C, D, and E are correct. A is correct. "Do you have a plan?" is one of the first questions a nurse should ask any suicidal client after confirming the client is having thoughts of killing themselves. Clients with concrete ideas are much more likely to attempt suicide than clients who do not have a plan. C is correct. "What is your plan?" is another critical question a nurse asks a suicidal client. D is correct. This question will depend on what the client tells you about their plan for committing suicide. For example, if they say they plan to shoot themselves, the appropriate question is, "Do you have a gun?" This is of the utmost importance for the client's safety. If they do have a gun or whatever item is needed to carry out their suicide plan, the nurse needs to have it confiscated immediately to keep them safe. E is correct. Asking about a client's previous suicide attempts is essential because previous suicide attempts may enhance the credibility of the client's current ideation. This is a pertinent question to ask the client.

The nurse is admitting a new client to an acute psychiatric facility and determines that they have suicidal ideations. Which of the following questions should the nurse ask this client? Select all that apply. "Do you have a plan?" "Does anyone know about your plan to kill yourself?" "What is your plan?" "Do you have the means or methods to carry out your plan?" "Have you attempted suicide previously?"

Choice B is correct. Delusion of persecution is when an individual is falsely convinced someone is out to get them or intends to cause them harm. This is a serious delusion because the client may react with violence.

The nurse is assessing a client experiencing psychosis. The client states, "I am convinced my wife and brother-in-law want to kill me." The nurse interprets this statement as a A. delusion of reference. B. delusion of persecution. C. delusion of grandeur. D. delusion of erotomania.

Choices A and E are correct. Individuals with Antisocial Personality Disorder have clinical features such as a disregard for others, deception, lack of empathy, and a failure to conform to societal norms.

The nurse is assessing a client with Antisocial Personality Disorder. Which of the following would be an expected finding? Select all that apply. Lack of empathy Grandiosity Preoccupation with orderliness Excessive attention-seeking Disregard for the right of others

Choices A and E are correct. Borderline personality disorder (BPD) is a common personality disorder that features extreme emotional lability, impulsivity, self-mutilative behaviors, and manipulative mannerisms. The client with BPD often utilizes narcissistic defense mechanisms such as denial, projection, and splitting.

The nurse is assessing client who has a borderline personality disorder (BPD). Which of the following would be an expected finding? Select all that apply. Self-mutilating behaviors Hypervigilance Emotional detachment Social inhibition Impulsivity

Choice B is correct. "Ineffective coping related to responsibilities required in the caregiver's role" is an appropriate nursing diagnosis for a caregiver who abuses alcohol and drugs to self-medicate to overcome caregiver stress.

The nurse is caring for a client whose caregiver is under significant stress and using drugs and alcohol as a means of self-medication to cope with caregiver stress. What would be the most appropriate nursing diagnosis in this situation? A. Ineffective coping related to alcohol and abuse B. Ineffective coping related to responsibilities required in the caregiver's role C. The client will make better lifestyle choices D. The client will attend two 12-step recovery programs per week for one month

Choice D is correct. Hospice is a service that provides comfort and dignity for clients with six or fewer months left to live. This service is flexible in that it may be rendered, inpatient and outpatient. Hospice services may be provided to individuals incarcerated or in long-term care. It also can be provided in specialized facilities. The portability of this service is one of its many benefits.

The nurse is planning a staff development conference about hospice services. Which of the following information should the nurse include? A. Hospice services are useful for symptom management of aterm-63cute diseases. B. Treatment is limited to pain management and symptom control. C. The goal is to implement curative therapies and treatments. D. Services may be offered in settings such as the home and inpatient.

Choice B is correct. A common mnemonic to remember is "the solution to pollution is dilution." When a client has a chemical burn, the highest priority is to copiously irrigate it (dilute it) with saline or water. Prompt irrigation of the area exposed to caustic substances ( acid, alkali) dilutes the chemical, attempts to neutralize the pH change in the skin, and decreases the extent of the dermal injury. Additionally, dilution lessens the risk of the caregiver getting burned by the chemical.

The nurse is triaging a child with bilateral lower extremity chemical burns. The nurse suspects that the child may have been abused. The nurse should take which initial action? A. Cover the affected area with sterile dressing B. Irrigate the affected area with saline C. Report the suspected abuse D. Document the findings

Choice A is correct. Alprazolam (Xanax) is a type of benzodiazepine. The patient is presenting with classic benzodiazepine drug withdrawal symptoms: anxiety, coarse hand/tongue/eyelid tremors, irritability, increased autonomic activity (tachycardia and sweating), orthostatic hypotension, and insomnia.

A patient presents with dizziness upon standing, bilateral hand tremors, inability to sleep, irritability, sweating, and a heart rate of 95. From what substance is the patient most likely experiencing these withdrawal symptoms? A. Alprazolam B. Nicotine C. Adderall D. Cocaine

The nurse is caring for a teenager with cystic fibrosis and is upset about missing so many days of school. The teenager appears to be withdrawn and reluctant to participate in the plan of care. Which nursing interventions would be most appropriate for this client? A. Arrange for another teenager with cystic fibrosis to come to talk with the client B. Obtain a prescription for antidepressant medication C. Modify future assignments to arrange for a consistent nursing team D. Have an older adult come and talk to the teenager about living with cystic fibrosis

Choice A is correct. Peer relationships are central to a teenager. A teenager with a chronic illness, such as cystic fibrosis, may be absent from school and school-related activities, which may impede social development. It is appropriate for the nurse to arrange a group therapy session(s) (or dialogue with another teenager). Teenagers are likelier to be open with individuals within the same age range than older adults. Considering the client's negative coping and reduced socialization opportunities, this would be an appropriate addition to the care plan.

Choices A, B, C, and D are correct. Delirium has an abrupt onset of symptoms that include - Impairments with attention that fluctuate in intensity Difficulty with insight, judgment and executive functioning Memory impairments Altered level of consciousness Emotional lability Causes of delirium include fluid and electrolyte imbalances, infection, medications, sensory alterations, or substance use (intoxication/withdrawal).

The nurse is assessing a client with delirium. Which of the following would be an expected finding? Select all that apply. Impaired insight into illness Difficulty with executive functioning Altered level of consciousness Emotional lability Insidious onset of symptoms

Choice B is correct. Word salad is a type of language and communication disturbance in which the client says words and phrases that are not indeed related to one another.

The nurse is caring for a client with schizophrenia, who is speaking words and phrases that are unrelated to one another. The nurse should document this communication pattern as A. pressure speech. B. word salad C. neologism. D. clang association.

Choice C is correct. The cornerstone of milieu therapy is to provide an all-inclusive (staff and clients) structured environment that fosters routine, safety, and acceptance. This environment enables healing and promotes positive outcomes.

The nurse is preparing a staff development conference on milieu therapy. Which of the following information should the nurse include? A. This type of environment is established in inpatient treatment facilities, emphasizing physical well-being. B. This therapy primarily focuses on helping clients develop emotional connections with individuals in the community. C. An emphasis of this therapy is the setting, the structure, and the emotional climate as important to the client's healing. D. The approach to milieu therapy is unstructured and allows clients to self-regulate what they feel should be allowed.

Choice D is correct. Rationalization is a higher-level defense mechanism that involves an individual justifying behavior that is often offensive or abnormal through statements that they believe provide validation. However, rationalizing the behavior is done to avoid authentic feelings such as guilt if they have done something wrong. The client missing their appointment because they overslept is rationalizing this choice because they perceived the appointment as pointless.

A nurse cares for a client who has missed their last appointment with the primary healthcare provider (PHCP). The client states, "I missed my appointment because I overslept, but I knew it would be pointless anyway." The client is demonstrating which defense mechanism? A. Projection B. Reaction formation C. Denial D. Rationalization

Choice D is correct. An activity, such as a workshop, is an excellent opportunity for staff members to learn about new cultures and to identify their feelings towards other cultures, religions, and/or ethnicities. Additionally, a workshop would allow the staff members an interactive opportunity to ask questions and engage in a discussion about the cultures being reviewed.

A nurse manager works on a unit where the nursing staff is having difficulty caring for clients from other cultural backgrounds. What is the most appropriate action for the nurse manager? A. Let the staff research articles on various cultures to become more familiar with those cultures. B. Transfer the nurses to other units where they can't be assigned to clients from different cultures. C. Rotate the nurses' assignments so they can all have the opportunity to care for clients from other cultures. D. Organize an activity that offers opportunities for the staff to learn about the cultures they might encounter at work.

Choice B is correct. A nurse's legal responsibility is to immediately report any suspected child abuse to the relevant authorities according to state and local law(s). Once any suspicion forms, the nurse is required to report the suspicion to the appropriate investigative agency or agencies per applicable law, which then assumes the investigation

A nursing student in a pediatric unit at a hospital asks the clinical nurse educator about a nurse's legal responsibilities in cases of suspected child abuse. Which of the following would be the most appropriate response by the nurse educator? A. A nurse is required to collect additional data to support their suspicion before taking further action. B. A nurse is required to directly report their suspicions to the local child protection agency and/or law enforcement agency. C. A nurse is required to talk to a child's parents regarding any suspected abuse. D. A nurse is required to talk to the health care provider (HCP) regarding their suspicions of child abuse.

Choice C is correct. Feeling connected to another person gives a sense of belonging and acceptance. The patient will be more likely to change after joining with another person. Change is necessary when a patient is exhibiting behaviors that are harmful to himself or others. Change can be implemented in many ways, but personal engagement, or talking, working with, and spending time with another person, can be useful in getting the message across about the high-risk behavior. With personal engagement, the patient is more likely to desire change because he feels a connection with another person.

A patient admits that he thinks he has a problem with drinking too much alcohol. The nurse talks with the patient about substance abuse and the adverse effects of alcoholism. Which best describes how personal engagement with a patient is an active method of change? A. The patient will understand the information more than if it were presented electronically. B. The patient will be less likely to be litigious toward the healthcare facility. C. The patient will more likely desire change after connecting with another person. D. The patient will feel as if he has made a new friend.

Choice B is correct. This is an appropriate response from the nurse because it offers reassurance to the client while providing an opportunity for the nurse to gain insight into the client's anxiety. This is an open-ended question that encourages the client to express their thoughts and feelings, which can be therapeutic. It allows the client to explore the root causes of their anxiety, which is essential for providing appropriate care.

A woman comes into the emergency department complaining of insomnia, anxiety, difficulty breathing, and a sense of impending doom. After being assessed by the physician, no physiological abnormalities were found. However, the client is still anxious and apprehensive. What is the most appropriate statement from the nurse to the client? A. "Don't worry, you're safe here. Just try to relax." B. "Can you think of anything that happened recently or in the past that might have triggered these feelings?" C. "We gave you something that should calm you down." D. "Take slow, deep breaths, and try to relax. Nothing bad will happen to you here."

Choice B is correct. The nurse should observe the client while eating and prevent the client from using the restroom for 90 minutes each meal to break the purging cycle. Although purging is traditionally associated with bulimia, purging is actually seen in both in both anorexia and bulimia (while this sounds very similar to bulimia, the primary difference is that in bulimia, clients are of normal or above-normal weight, whereas those with anorexia nervosa (even the binge eating/purging type) have a significantly low body weight). Binge eating with purging occurs in 30 to 50% of anorexia clients; therefore, the post-meal restroom restriction is needed to ensure anorexia clients are not purging.

At an eating disorder treatment center, a nurse is caring for a client with anorexia nervosa who has recently arrived at the facility. Which intervention should the nurse applterm-24y following the client's meals? A. Instruct the client to exercise by going for a walk following meals B. Restrict the client from using the restroom for 90 minutes after each meal C. Ask the client to lie down for two hours after each meal D. Encourage the client to begin an intense exercise program, with short exercise sessions after each meal

Choice B is correct. This patient has bruises on her thigh, wrists, and upper back that are in different stages of healing, which is a reliable indicator of abuse. Bruising on these parts of the body is not a common area for 2-year olds to injure. Typical areas of injury are the knees elbows and chin. Thigh, wrist, and upper back injuries can be due to grabbing, burning, or pushing. The department of child and family services (DCFS) needs to be contacted by the nurse because nurses are mandated reporters. Recognizing signs of abuse is extremely important.

Parents bring their 2-year old daughter into the emergency department after picking her up from her aunt's house. They are concerned that she has an upper respiratory infection. The nurse notices bruises on the patient's posterior thigh, wrists, and upper back. They appear to be in different stages of healing. Once the patient is stable after administering a bronchodilator and steroid, what should the nurse do? A. Question the parents B. Call the department of child and family services (DCFS) C. Call poison control D. Obtain an arterial blood gas (ABG)

Choice B is correct. When a client is experiencing a panic attack, somatic symptoms such as hyperventilation, perspiration, chest discomfort, and nausea are likely. However, the nurse should always prioritize physical needs/reports such as chest pain. The nurse should obtain a 12-lead electrocardiogram as this is an effective way to rule out acute coronary syndrome (ACS). ACS may cause similar symptoms, such as a feeling of impending doom, and the nurse should intervene and obtain this necessary test.

The emergency department (ED) nurse triages a client experiencing a panic attack. The client reports nausea, chest discomfort, and a feeling of impending doom. The nurse should plan to take which priority action based on the client's symptoms?term-73 A. Assess the client for suicide B. Obtain a 12-lead electrocardiogram (ECG) C. Develop a therapeutic rapport with the client D. Inquire about the precipitating event

Choice B is correct. Psychotherapy is the gold standard treatment for a client with an eating disorder. While therapeutic approaches may differ, the most common psychotherapeutic approach is cognitive-behavioral therapy (CBT). CBT is helpful because it examines the client's distorted thoughts to remedy the harmful behavior. Changing the client's negative thoughts regarding food and their self-image is essential in the management of most eating disorders.

The nurse cares for a client newly diagnosed with anorexia nervosa in the mental health unit. The nurse should plan which intervention in the client's plan of care? A. allow the client to pick out items on the menu B. obtain an order for the client to attend psychotherapy C. encourage the client to select their meal times D. obtain a prescription for fluoxetine

Choices A, C, E, and F are correct. A client experiencing opioid withdrawal will experience symptoms such as abdominal cramping, diarrhea, nausea, rhinorrhea, piloerection, diaphoresis, tachycardia, hypertension, insomnia, and agitation.

The nurse is assessing a client with opioid withdrawal. Which of the following would be an expected finding? Select all that apply. Diaphoresis Bradycardia Irritability Hypotension Rhinorrhea Abdominal cramps

Choice B is correct. PTSD is characterized by an individual who has experienced (or witnessed) a traumatic event such as sexual assault, combat, violence, or medical illness. The client then experiences significant cognitive, affective, and behavioral responses to stimuli reminding them of the trauma they experienced. This chronic psychiatric condition causes a client to experience manifestations such as night terrors, avoidance of anything that may trigger trauma memories, being easily startled, decreased concentration, hypervigilant, and sleep disturbances. This may cause the client to feel 'always on edge.' Dissociative symptoms may occur with PTSD, such as derealization or depersonalization.

The nurse is assessing a client with post-traumatic stress disorder (PTSD). Which assessment finding would be expected? A. Delusions of grandeur B. Hypervigilance C. Circumstantial speech D. Flight of ideas

Choice C is correct. Negative symptoms of schizophrenia include anhedonia, avolition, alogia, affective flattening, or blunting. Reminding the client that they had a birthday party and how it was would provoke an emotional response (reminding them of a happy time, etc.). Those with affective blunting do not display emotion even when provoked with an emotionally charged line of questioning. Choice E is correct. One of the negative symptoms is anhedonia. Anhedonia is the loss of recreational and sexual interest and decreased relationships with friends/family. Inquiring about a client's previous hobby and asking if they have re-engaged with that hobby is an effective way of inquiring about this negative symptom.

The nurse is assessing a client with schizophrenia who was recently prescribed lurasidone. Which questions by the nurse would be most appropriate in determining the presence of negative symptoms? Select all that apply. "Have you found yourself more distracted than usual?" "Do you have any thoughts of harming yourself?" "You recently had a birthday party, how was it?" "Do you have any thoughts of harming others?" "It says here you enjoy playing tennis. Have you been playing recently?"

Choice B is correct. Removing the client from the situation is a priority because the situation may continue to escalate. This is an effective statement because it takes the client away from the situation and offers them a choice so they do not feel powerless. A strategic approach to dealing with an aggressive client is to be assertive but offer options when possible.

The nurse is caring for a client in the mental health unit who has become verbally aggressive with other clients while in the dining room. Which statement would be appropriate for the nurse to make to the client? A. "Let's discuss your concerns in a private room with the door closed." B. "Do you want to go to your room or to the quiet room for a while?" C. "I think you should take a few minutes to calm down." D. "What is going on right now?"

Choices B, C, E, and F are correct. For a client demonstrating aggression, the nurse should respond quickly and calmly approach the client. The nurse should limit inflections in their voice to decrease the perception of aggression. The nurse should also maintain personal distance between themselves because if this escalates, the nurse has an appropriate distance from themselves and the client. Providing the client with several options is helpful as it decreases the client's feeling of powerlessness.

The nurse is caring for a client who is demonstrating signs of aggression. The nurse should plan to take which action? Select all that apply. Use therapeutic touch Use genuineness and empathy Use a calm, clear tone of voice Talk with the client in a closed private room Give several clear options Respond as early as possible

Choice C is correct. A client experiencing acute mania manifests symptoms such as inflated self-esteem, flight of ideas, psychomotor agitation, and an expansive affect. The client experiencing mania often has difficulty sleeping and exerts excessive physical energy. Thus, the nurse must meet the client's nutrition needs by offering high-calorie, small, frequent meals. This is the priority based on Maslow's Hierarchy of Needs (physiological).

The nurse is caring for a client who is experiencing acute mania. Which of the following actions should be prioritized by the nurse? A. Plan structured solitary activities B. Redirect the client's speech and ideas C. Provide high-calorie, small, frequent meals D. Initiate a psychiatry referral

Choices B and C are correct. Choice B is correct. In this scenario, the nurse offers to sit in silence with the client. Therapeutic silence with individuals struggling with depression can create a safe and reflective space, foster deeper communication, encourage self-reflection and emotional processing, reduce pressure and anxiety, enhance active listening, and promote self-expression. Choice C is correct. Effective therapeutic communication aims to establish trust, provide support, and encourage the client's expression of thoughts and feelings. Asking open-ended questions in a supportive, non-judgmental way offers support to the depressed client.

The nurse is caring for a client who is struggling with severe depression. Which of the following statements would demonstrate effective therapeutic communication with this client? Select all that apply. - "Great work today in group therapy Steve, you were really talkative today!" - "I'd like to just sit with you for a while Steve." -"Tell me how you're feeling Steve. I'd like to understand." -"Why are you feeling depressed today Steve?" -"I know exactly how you feel. I've been through the same thing."

Choices A, C, and D are correct. Individuals with Borderline Personality Disorder (BPD) often engage in self-harm/parasuicide behaviors in which the intent is not death. These gestures may be superficial cutting, etc. All clients should be assessed for suicide regardless of their diagnosis. Therapeutic boundaries should be established as a characteristic of this personality disorder is polarizing individuals and splitting. Referring the client for group therapy is one of the cornerstone treatments for BPD.

The nurse is caring for a client with Borderline Personality Disorder. Which of the following actions should the nurse take? Select all that apply. Assess the client for suicidal ideation Encourage independent decision-making Establish therapeutic boundaries Refer the client for group therapy Encourage social relationships

Choice C is correct. Reflection is a way of helping clients better understand their thoughts and feelings. By utilizing a question, simple statement, or the client's own words, the nurse may convey their observations of the client.

The nurse is educating a new graduate nurse on different forms of therapeutic communication. Select the form of therapeutic communication which is accurately paired with the correct description of that form of therapeutic communication. A. Seeking Clarification: Utilizing open-ended questions rather than closed-ended questions B. Offering General Leads: Ensuring the client fully understands the sent message C. Reflection: By repeating the client's words back to the client, the nurse conveys that they are actively listening while concurrently encouraging further expression from the client D. Offering Self: Giving the client advice based on the opinion of the nurse

Choice C is correct. Exploring the content of the client's delusion is important because this assessment will determine if the delusion has any logic (unlikely) and will help foster a therapeutic relationship with the client. Helping the client come to the realization that the delusion is just that; a delusion can be a challenge. This challenge is often mitigated when a therapeutic rapport is established.

The nurse is performing an assessment on a client. The client tells the nurse, "You people are part of the government plotting to destroy me." The nurse should respond with which appropriate statement? A. "Would you like me to come back later for your assessment?" B. "I believe you and think we should explore why you feel this way." C. "Tell me more about someone trying to destroy you." D. "Let us talk about your current medication and how it can help with those thoughts."

Choices A, B, and E are correct. Divorce or parental separation is traumatic for all ages, including adolescents. It is highly recommended that telling children and adolescents about divorce be planned and best delivered by both partners simultaneously. This is an ideal setup because it establishes a unified front of support at a time when the child or adolescent may feel lost. The parents should not avoid the discussion of divorce because it is unsettling for the child to have a sense of confusion or ambiguity regarding the parental arrangement. Addressing the divorce with the children clearly and empathetically is best. Providing physical and emotional reassurance, such as holding the child's hand, offers comfort. It is expected that children may react negatively with a sense of resentment. This resentment can be ameliorated by keeping the channels of communication open and conveying both physical and emotional support.

The nurse is teaching parents planning to tell their children about their divorce. Which of the following information should the nurse include? Select all that apply. - "Do not avoid telling the children about the divorce." - "Provide physical and emotional reassurance to the children." - "Try not to cry in front of the children." - "Limit the amount of time discussing the divorce." - "Children may react negatively with resentment."

Choices A, C, and E are correct. A is correct. Creating a schedule is one of the most critical aspects of treatment for clients with OCD. In this schedule, it is essential to allow time for the ritual - not allowing time for the compulsive activity will dramatically increase anxiety. C is correct. Adding time for meditation into the daily schedule is an appropriate intervention. Meditation is an excellent coping mechanism and can be added to replace some of the handwashing. E is correct. Selective serotonin reuptake inhibitor (SSRI) medications are commonly used to help clients manage compulsive behaviors. Examples of SSRIs include fluoxetine, fluvoxamine, and sertraline.

The nurse is working with a client who suffers from obsessive-compulsive disorder (OCD). The client has an obsession with the dangers of germs and performs compulsive hand washing hundreds of times per day. Which of the following should the nurse include in this client's treatment plan? Select all that apply. - Create a schedule for the hand washing ritual. - Teach the client about the dangers of over washing their hands. - Incorporate meditation into their daily schedule. - Block the sink so the client is not tempted to wash their hands. - Administer fluoxetine as ordered.

Choice C is correct. IPV against men is overwhelmingly underreported because of the stigma, masculinity expectations, shame, and certain laws that may favor women. Men oftentimes may sustain physical injuries to the genitals, verbal devaluation, and unprovoked physical attacks while sleeping. The nurse needs to keep an open mind regarding IPV because men may be the victim of the abuse and are not always the perpetrator.

The nurse plans a staff development conference about intimate partner violence (IPV). Which of the following statements, if made by a participant, would indicate a correct understanding of the conference? A. "Nurses are responsible for screening select individuals for intimate partner violence." B. "The nurse should tell the client that information about IPV will not be shared with anyone else." C. "Men may not report abuse because of a stigma of being abused by a woman." D. "Physical injuries from IPV are usually overtly seen on the face and the hands."

Choice B is correct. The psychiatric nurse would be most effective in preventing further inappropriate episodes by assisting the client in understanding what may have triggered the event.

The psychiatric nurse is providing care for a patient who has just calmed down after exhibiting inappropriate behaviors related to bipolar disorder. The nurse knows that which of the following is the best way to help prevent another unseemly episode? A. Identify the consequences of the behavior. B. Assist the client in understanding triggering events or feelings that may have lead to the outburst. C. Ensure that the patient's safety is upheld. D. Offer the patient clear options to deal with their current behavior.

Choice D is correct. The term "therapeutic milieu" is used in psychiatric units to describe the planned and therapeutic elimination of all triggers and stressors within the unit to facilitate the client's development of better coping skills. Additional information on this topic is included in the table below.

While conducting a class for new graduate nurses working on the psychiatric unit, one of the new graduate nurses asks you to elaborate on the term "therapeutic milieu." Which of the following responses most accurately describes a therapeutic milieu? A. "'The treatment for depression where the client is given a short-acting anesthetic, and a small amount of electric current is delivered, causing a small seizure to occur." B. "The ability of a client to learn new skills by imitating another person, typically the therapist, allowing the client to learn through imitation." C. "The use of incentives, motivation, and rewards to help clients control their symptoms to facilitate the development of better coping skills in the clients." D. "A 'therapeutic milieu' is a healthy social structure within an inpatient setting or structured outpatient clinic. Within these small versions of society, individuals are safe and increase their ability to interact with the outside community."

Choices A, B, and D are correct. These are examples of cognitive responses to stress. Psychological responses are both emotional and cognitive. They include feelings, thoughts, and behaviors. Emotional responses usually involve anxiety, fear, anger, and depression; whereas, cognitive responses affect thought processes.

You are performing a thorough assessment of a client to determine all responses to stress. Which of the following are examples of cognitive responses to stress? Select all that apply. Difficulty concentrating Poor judgment Depression Forgetfulness Lethargy Aggressiveness

Choice B is correct. Even though the client is involuntarily admitted, the client does not lose the right to provide, withhold, and/or withdraw any previously provided informed consent (if applicable). Informed consent for electroconvulsive therapy (ECT) must be obtained from the client voluntarily, regardless of the client's involuntary admission status.

A nurse is caring for an involuntarily admitted client with an order for electroconvulsive therapy (ECT). Before transferring the client to the procedure room, the nurse notes that the consent form is unsigned. The nurse understands that: A. Informed consent should be obtained from the client's spouse. B. Informed consent should be obtained from the client. C. Informed consent is not required. D. Informed consent needs to be obtained from the court.

Choice D is correct. Avolition is a lack of motivation and is a key feature in schizophrenia and some depressive disorders. Avolition is categorized as a negative symptom associated with schizophrenia.

The nurse is caring for a client demonstrating avolition. The nurse would expect to observe the client have which of the following? A. Loss of balance B. Full range of affect C. Diminished expression D. Lack of motivation

Choice C is correct. The most appropriate initial intervention is for the nurse to remove the client from the stressful situation and provide the client with a calm, quiet place to rest. This intervention will help decrease the anxiety level of the client.

A client diagnosed with an anxiety disorder arrives at a busy local mental health clinic. Due to the significant number of individuals moving throughout the clinic, the client unexpectedly suffers an acute anxiety attack. Which nursing interventions would be the most appropriate for the clinic nurse to initiate initially? A. Administer one tablet of alprazolam to the client immediately B. Talk to the client to explore their feelings C. Accompany the client to a vacant room to let the client rest D. Take the client's vital signs

Choice D is correct. The patient is showing signs of opiate intoxication. Opiate intoxication is characterized by pinpoint pupils, slurred speech, inattention, lethargy, psychomotor retardation, and impaired memory, judgment, and social function. Changes to vitals include hypotension, decreased heart rate, reduced temperature, and lower respiratory rate.

A patient presents to the emergency department with pinpoint pupils, poor attention, and slurred speech. Upon assessment of vitals, the patient is found to have a BP of 92/60 mmHg, HR 58, RR 14, and T 96.8 degrees F. Which substance is this patient's intoxication most likely related to? A. Alcohol B. Cannabis C. Cocaine D. Opiates

Choice B is correct. The client is placing blame on others and not taking responsibility for her behavior.

After failing a final anatomy exam, a student is angry with the instructor and talks negatively about her. What defense mechanism is this an example of? A. Acting out B. Projection C. Compensation D. Reaction-formation

Select two (2) actions the nurse should take Provide therapeutic touch Limit interaction with the client Place the client in seclusion Ask if the client hears any voices Crush the olanzapine in the client's food Reassign the client to a private room

Ask if the client hears any voices; Reassign the client to a private room

heroin; obtain a prescription for an antihypertensive; blood pressure

Based on the client assessment, the client is likely intoxicated with _______ The nurse should immediately _______ based on the client's ________

acute

Based on the physician's progress note, the client is in which phase of schizophrenia? prodromal acute stabilization maintenance

The nurse is conducting a suicide assessment on a client. While reviewing the assessment data, the nurse is most concerned about the client A. having alcohol dependence. B. taking an antidepressant for the past five years. C. newly diagnosed with psoriasis. D. just started attending a support group for individuals with psoriasis.

Choice A is correct. Alcohol dependence is a significant risk factor for suicide. Alcohol dependence increases aggressivity and impulsivity and causes deterioration in cognitive capacity and flexibility to find constructive coping strategies. This can make the client feel quite emotional and engage in high-risk behaviors while having poor judgment. The suicide rate is 50 times higher in alcohol-dependent persons than in those who are not alcohol-dependent.

suicide; feelings of hopelessness

Complete the following sentence from the list of options The greatest concern for this client is _________ evidenced by the client's ________

Which prescriptions should the nurse anticipate from the primary healthcare provider (PHCP) based on the history and physical? Select all that apply. levodopa-Carbidopa methylprednisolone lorazepam intravenous fluids venlafaxine Levothyroxine

Options C, D - Correct - Catatonia is a serious psychiatric syndrome that may occur with psychiatric and medical conditions. The gold standard treatment for catatonia is benzodiazepines such as lorazepam. Lorazepam is preferred because of its modulating effects on the neurotransmitter GABA. The nurse should also request a prescription for intravenous fluids because the clinical data suggests dehydration (skin tenting and dry mucous membranes) which is a likely consequence of catatonia.

Choice C is correct. Having a difficult time eating nearly half a year after an injury is not a healthy coping mechanism. While typical in the first few weeks following a loved one's death, this length of time indicates a need for intervention.

The home care nurse is assessing a client whose husband passed away nearly half of a year ago. Which of the following is not a robust coping mechanism? A. Looking at photographs of the client's husband B. Getting together with friends more frequently than before C. Having difficulty eating D. Expressing a strong desire to visit their husband's grave every few weeks

Choice B is correct. The cardinal feature of narcolepsy is daytime sleepiness, in which they may have sleep attacks that cause an individual to rapidly doze off with little warning. If a client is meeting the treatment goals, they would report decreased daytime sleeping, which would lead to increased productivity.

The nurse is caring for a client who has narcolepsy. Which of the following would indicate the client is achieving the treatment goals? A. Increased focus and attention. B. Decreased daytime sleeping. C. Increased daytime energy. D. Decreased social avoidance.

Choices B and D are correct. A client experiencing paranoia may be very conspiratorial, and while it is important to reinforce reality, it would be appropriate to acknowledge their feelings. Involving the client in the decision-making process and avoiding any surprises is essential. Consistent caregivers are recommended because this cements the therapeutic relationship with staff.

The nurse is developing a plan of care for a client admitted to the mental health unit with significant paranoia. Which of the following should the nurse include in the client's plan of care? Select all that apply. - Plan competitive activities with other clients. - Maintain consistent caregivers. - Establish a rapport using therapeutic touch. -Involve the client in decision-making. - Develop a plan of care that is unstructured. -Immediately enroll the client in group therapy.

Choice B is correct. Physical dependence is when a client needs a drug to avoid unpleasant withdrawal symptoms. Physical dependence is different from addiction, where addiction causes an individual to lose control over an intense need for a drug. Addiction may cause an individual to make consequential choices to obtain the drug, adversely affecting the individual.

The nurse is teaching a class on substance use disorders. It would be correct for the nurse to characterize physical dependence as A. obsessive desire for the euphoric effects of a drug. B. a need for a drug to avoid physical withdrawal symptoms. C. severe effects that may be life-threatening. D. unpleasant symptoms related to the absence of a drug.

- You may have more energy with the medication. - Take this medication in the morning to prevent sleep problems.

The nurse prepares to administer the prescribed bupropion. Which two (2) teaching points should the nurse include? - This medication may cause you to gain weight. - You may notice a decreased libido while on this medicine. - Have a diet that has a consistent intake of salt and water. - You may have more energy with the medication. - You will need ongoing laboratory work while on this medicine. - Take this medication in the morning to prevent sleep problems.

Choices B, C, E, and F are correct. Domestic violence (including physical, emotional, and sexual abuse) occurs throughout society. It is present among all racial, social, and economic groups. Health issues related to domestic violence include physical injury from the assault and chronic health problems that may emerge, either as a complication of traumatic injury or as a physical response to ongoing stress from violence or neglect. Health issues related to domestic violence include physical injury from the assault itself, such as bruises and broken bones (Choice B). Families experiencing domestic violence/ physical abuse have more unintended pregnancies, miscarriages, abortions, and low-birth-weight babies (Choice C). Families experiencing domestic violence have higher rates of substance abuse and depression (Choices E and F).

What health issues might you expect to find in a client that is a victim of domestic violence? Select all that apply. - Upper respiratory infections - Bruises and broken bones - Unintended pregnancies - Repetitive strain injuries - Alcoholism - Depression

Choice A is correct. The highest priority of care for a client with the nursing diagnosis of"at risk for self-directed violence" is the preservation of life, as consistent with Maslow's hierarchy of needs.

What is the greatest priority of care for a client with the nursing diagnosis "at risk for self-directed violence"? A. The preservation of life B. The assessment of the client C. Encouraging the expression of the client's feelings D. Determining the client's social support systems

Choice B is correct. The priority that the nurse should consider in terms of this client's current psychological state is the possibility that this severely depressed client has planned suicide; this may occur when a severely depressed client becomes far less depressed than they were in the past. Although this client may be effectively treated with antidepressant medications and cognitive behavioral therapy, the priority concern is associated with a heightened risk of suicide.

You have been caring for a severely depressed client in the community. When you see this client today, the client is far less depressed than they were in the past. What priority should the nurse consider in terms of this client's current psychological state? A. The client has resolved the depression. B. The client may have planned their suicide plan. C. The antidepressant medications are effective. D. Their cognitive behavioral therapy is effective.

The nurse should prioritize _____ because of the client's _____

administering the saline infusion, vital signs

The client is at highest risk of developing ___ as evidenced by the client's ____

schizotypical personality disorder; illogical thought content