mental health exam 2

A client in an inpatient setting has a delusion that there are a multitude of undetectable noxious gases in circulation that have the potential to poison the client and others. Which of the nurse's responses is most therapeutic?

"I can assure you that you are actually very safe here." Assuring a client of his or her safety is a more therapeutic intervention than expressing exasperation with the client's delusions, arguing against them, or implicitly confirming them.

Which statement made by a client raises the greatest concern that the client may be experiencing relationship violence?

"I don't know what else I can do to keep him from getting angry at me." A warning sign of relationship violence is feeling that you must change your life or yourself so you won't anger him or her. The remaining statements, while troublesome, are not as clearly associated with behaviors of violence.

The nurse is providing education to a client prescribed clomipramine to help with obsessive-compulsive disorder. Which statement by the client indicates the teaching was effective?

"I may have a risk of suicidal thoughts with the medication." The client would have a risk of suicidal thoughts so needs to be aware so that these can be reported to the healthcare provider. The medication would take usually several weeks before the client notices therapeutic effects so should not expect to feel better in a week. The medication also has a side-effect of sedation so that the client should be careful with driving and operating heavy machinery. The medication is best taken with food, not on an empty stomach.

After teaching a client with schizoaffective disorder about the condition and treatment, the nurse determines that the education was successful when the client states what?

"I need to eat properly so that I can control my weight." Client education should focus on nutrition and prevention of weight gain, which is a side effect of medication therapy. Establishing a regular sleep pattern by setting a routine can help to promote or reestablish normal patterns of rest. Establishing a daily routine can help address mood symptoms. Medication should not be stopped if the client feels better.

A mental health nurse presenting an educational program on rape for high school students responds to the statement, "Women cry rape often times just to get even with the guy," by offering which answer?

"Actually, fewer than 2% of all reported rapes are found to be false." Rape is an underreported crime due to feelings of guilt on the part of the victim. Only approximately 2% of all reported rape cases are false.

The nurse is admitting a client with obsessive-compulsive disorder whose compulsion is washing hands. What should the nurse explain to the client?

"Applying lotion will help keep your skin from breaking down." Clients when newly admitted should not be prevented from engaging in rituals because this will increase the client's anxiety level. The nurse can allow this initially but will later set a schedule for this. A concern over frequent handwashing is maintaining skin integrity so the client will need to apply lotion to help with this. All clients would not need to stay in their hospital rooms but allowed to interact with the environment as appropriate for the unit. Medication can be prescribed to help with the compulsion.

A client with posttraumatic stress disorder (PTSD) tells the nurse the client feels the client is a burden on the health care system. What would be the most appropriate response from the nurse?

"Expressing your feelings will de-stress you and we want you to get well soon." Clients with PTSD may have negative feelings associated with themselves. They often tend to believe that they are a burden to others. In such cases, the nurse should give positive feedback to the client for expressing feelings. This encourages the client to be more expressive about personal feelings. Telling the client to calm down and avoid talking would discourage the client from talking. The nurse should avoid using this statement. Telling the client to control the client's anger reinforces the feeling of self-blame in the client, thus this statement should not be used. Saying that looking after the client is the nurse's work indicates that the client is a burden. It reinforces the feeling of self-blame in the client.

The nurse is working with a client with schizophrenia who has cognitive deficits. It is time for the client to get up and eat breakfast. Which statement by the nurse would be most effective in helping the client prepare for breakfast?

"First, wash your face and brush your teeth. Then put your clothes on." The client needs clear direction, with tasks broken into small steps, to begin to participate in the client's own self-care. The client, not the nurse, should perform the steps.

In working with the individual and family, which is the most accurate statement the nurse can make in order to teach the client and family about schizophrenia?

"Individuals with schizophrenia do have differences in brain structure and function that cause a variety of symptoms such as lack of motivation and hearing voices." Excessive amount of the neurotransmitter dopamine allows nerve impulses to bombard the mesolimbic pathway, the part of the brain normally involved in arousal and motivation. Normal cell communications are disrupted, resulting in the development of hallucinations and delusions. Abnormalities in brain shape and brain circuitry are being researched.

Which statement made by the nurse to the family of a client diagnosed with obsessive-compulsive disorder (OCD) demonstrates the best general understanding of the chronic nature of the disorder and its management?

"It's important to know that the symptoms will intensify during periods of stress." OCD is a chronic, progressive disease. Symptoms wax and wane over time, increasing during periods of stress. While the other statements are accurate, they do not provide the most general, encompassing information regarding the management of this chronic, progressive disorder.

A client with schizoaffective disorder is prescribed clozapine to treat symptoms. Which instructions would the nurse provide?

"Keep an eye on your weight, and if you gain weight rapidly, notify your doctor." The client should be cautioned to notify the health care provider if the client has rapid weight gain because this may be indicative of excessive fluid retention. Dry mouth and sedation, common side effects of any antipsychotic agent, do not require the client to notify the physician. Urinary changes are not associated with clozapine use. Although clozapine is associated with an increased risk of infection, it would be important to notify the physician if the client's urine odor becomes foul, possibly suggesting a urinary tract infection.

Which statement by the nurse demonstrates an understanding of the role automatisms have in a panic attack?

"The client taps her fingers very rapidly when she is feeling anxious." Automatisms are automatic, unconscious mannerisms associated with anxiety. Examples include tapping fingers, jingling keys, or twisting hair. Automatisms are geared toward anxiety relief and increase in frequency and intensity with the client's anxiety level. None of the remaining options accurately state the fact that the tapping identifies the level of anxiety a client is experiencing but does not manage or less the emotion.

The nurse is admitting a client to the hospital. The nurse gives the client information about patient rights while in the hospital. Which statement by the client indicates that more teaching is needed?

"The doctor can copy my information and send it to my son." Privacy refers to that part of an individual's personal life that is not governed by society's laws and government intrusion. Protecting an individual from intrusion is a responsibility of health care providers.

A nurse is teaching a group of nursing students about the concept that long term stress causes an increase in the wear and tear on the brain and body. Which statement by the nursing student indicates understanding of this concept?

"The increase in the wear and tear on the body from stress is allostatic load." Allostatic load is the consequence of the wear and tear on the body and brain and leads to ill health. Homeostasis is the body's tendency to resist physiological change and keep bodily functions relatively consistent, well-coordinated, and usually stable. Chronic stress can be quite damaging to both mental (depression) and physical (immune), cardiovascular, and metabolic health. Many changes are not reversible. Adaptation is a person's ability to survive and flourish.

Which client exhibits the characteristics that are typical of the prodromal phase of schizophrenia?

A 20-year-old is experiencing a gradual decrease in the ability to concentrate, be productive, and sleep restfully. Gradual, subtle behavioral changes appear during the prodromal phase of schizophrenia, such as tension, the inability to concentrate, insomnia, withdrawal, or cognitive deficits. No symptoms are present in the premorbid phase, and relapses occur in the progressive and chronic phases. Diagnosis of the disease marks the beginning of the onset phase.

Which client is most likely to be diagnosed with body dysmorphic disorder (BDD)?

A client who firmly believes that everyone who sees the client fixates on the size of the client's ears BDD is characterized by a disproportionate focus on a minor physical characteristic. Clients with BDD do not necessarily binge and purge or engage in dangerous weight loss. Underestimation of obesity is not typical of BDD.

The client has begun to wash the hands every hour due to the fear of germs becoming embedded in the client's skin leading the client to develop cancer. The nurse interprets this behavior as indicating which condition?

A compulsion Compulsions are ritualistic behaviors that people feel compelled to perform either in accord with a specific set of rules or in a routine manner. A repeated action performed as the result of a persistent thought is termed a compulsion. Obsessions refer to recurrent, intrusive, and persistent ideas, thoughts, images, or impulses. Compulsions are the behaviors people with obsessive-compulsive disorder will carry out in order to neutralize the anxiety caused by the obsessions. Panic attacks typically are characterized by a discrete period of intense apprehension or terror without any real accompanying danger, accompanied by at least four of 13 somatic or cognitive symptoms. Acute stress disorder occurs within the first month of exposure to extreme trauma: combat, rape, physical assault, near-death experience, or witnessing a murder.

During an admission assessment with a psychiatric-mental health nurse, a client states that the client hears the voice of God in the client's head and the voice is telling the client that the client is worthless. How should the nurse document this symptom?

A hallucination Hallucinations are sensory perceptions with a compelling sense of reality but with no actual objective basis. During auditory hallucinations (the most common form), clients may hear the voice of God or close relatives, two or more voices with a running commentary about the client's behavior, or voices that command certain acts. Usually the voices are obscene, accusatory, or insulting. They may call clients names and make nasty remarks.

The most important factor in the person's stress response is what?

Adaptive coping strategies The most important factor in a person's stress response is the ability of engage in adaptive coping behaviors. This ability can assist a person in developing resilience, or the ability to "bounce back" when faced with stress and stressful situations. The immune system, having a supportive network of friends, and understanding of relaxation techniques are also influencing factors when considering how an individual responds to stress; however, the correct option relates to an internal, sustainable strength that comes from adaptive coping.

A client was admitted to the psychiatric intensive care unit with schizophrenia. Among the client's signs and symptoms, the client was experiencing nihilistic delusions. The nurse understands that these delusions involve a belief about what?

An impending calamity Delusions are erroneous fixed, false beliefs that cannot be changed by reasonable argument. Nihilistic delusions involve the belief that one is dead or a calamity is impending. Grandiose delusions involve the belief that one has exceptional powers, wealth, skill, influence, or destiny. Persecutory delusions involve the belief that one is being watched, ridiculed, harmed, or plotted against. Somatic delusions involve beliefs about abnormalities in bodily functions or structures.

After assessing a client with schizophrenia, the nurse notes that the client exhibits signs and symptoms related to being unable to experience pleasure. The nurse documents this finding as what?

Anhedonia Anhedonia refers to the inability to experience pleasure. Diminished emotional expression is reflected by a restriction or flattening in the range and intensity of emotion. Alogia refers to a reduced fluency and productivity of thought and speech. Avolition refers to withdrawal and inability to initiate and persist in goal-directed activity.

A client has sought treatment because of the overwhelming anxiety the client experiences regarding the safety of the client's young children. The client admits that the client will not normally let the client's children leave the client's sight for fear that they will be abducted, abused, or injured. The client is unable to function at work as a result of this anxiety. The nurse would recognize that this client experiences which condition?

Anticipatory anxiety Anticipatory anxiety exists in the context of phobia. People with phobias develop anticipatory anxiety even when thinking about possibly encountering the dreaded phobic situation (i.e., danger to the client's children). The anticipatory anxiety in this case is so severe that the client is unable to function in certain situations leading to hardship. Signal anxiety refers to the natural anxiety mechanism that communicates danger or motivation for needed change. Fear refers to feeling afraid or threatened by a clearly identifiable external stimulus that presents a danger to a person. Derealization refers to a stage in the experience of anxiety when a person senses that things are not real.

Panic disorder is treated with cognitive-behavioral techniques, deep breathing, and relaxation, in addition to what?

Antidepressants Panic disorder is treated with cognitive-behavioral techniques, deep breathing and relaxation, and medication such as benzodiazepines, selective serotonin reuptake inhibitors, tricyclics, and antihypertensives, such as clonidine and propranolol.

Which medication classification has been found to be effective in reducing or eliminating panic attacks?

Antidepressants Tricyclic and monoamine oxidase inhibitor antidepressants have been found to be effective in treating clients with panic attacks. Why these drugs help control panic attacks is not clearly understood. Anticholinergic agents, which are smooth-muscle relaxants, relieve physical symptoms of anxiety but do not relieve the anxiety itself. Antipsychotic drugs are inappropriate because clients who experience panic attacks are not psychotic. Mood stabilizers are not indicated because panic attacks are rarely associated with mood changes.

When explaining the difference between anxiety and fear, the mental health nurse shares what? Select all that apply.

Anxiety involves experiencing subjective, uncomfortable feelings resulting from unknown causes Fear results in objective, physical responses caused by real danger Anxiety is likely to result from an attempt to overcome stress When explaining the difference between anxiety and fear, the mental health nurse shares that anxiety involves experiencing subjective, uncomfortable feelings resulting from unknown causes. At some point in time, all people experience anxiety, as this is a normal human response to a threat or stress. It is inaccurate to say that people who experience anxiety tend to use maladaptive coping mechanisms. Obsessive compulsive disorder is a complex anxiety disorder that not only has its roots in abandonment, but there are multiple factors contributing to why this anxiety disorder may be present in individuals.

A client with schizoaffective disorder is having difficulty adhering to the medication regimen that requires the use of several agents. The client also is experiencing several side effects contributing to this nonadherence. The physician plans to change the client's medication. Which agent would the nurse anticipate that the physician would prescribe?

Aripiprazole The medication regimen for a client with schizoaffective disorder is complex and may include antipsychotics, mood stabilizers, antidepressants, and occasional antianxiety agents. The use of these agents can lead to multiple side effects and possible interactions. Aripiprazole exerts an antidepressant effect and may replace polypharmacy, thus reducing drug costs, the risk of drug interactions, and potential adverse drug effects and possibly enhancing adherence.

The nurse is assessing a new client and the client's 3 year-old child. During the interview, the child clamors to sit on the nurse's lap and repeatedly tries to lean into the nurse's chest. What is the nurse's best action?

Assess the child for further signs of disinhibited social engagement disorder Disinhibited social engagement disorder exists when children are overly familiar with strangers. Reactive attachment disorder involves the opposite behavior. The nurse should assess whether the child often behaves like this, but the child should not be the source of this information. The child's friendships do not have an obvious link with the present behavior.

A client with a diagnosis of posttraumatic stress disorder (PTSD) has been brought to the emergency department (ED) by concerned family members, who state that the client is experiencing a "nervous breakdown." The ED nurse should prioritize what aspect of care during the initial care of the client?

Assessing the client's risk for self-harm and ensuring safety In an emergency context, the assessment of suicidality and the risk for self-harm is a priority. The nurse should perform each of the other listed actions, but measures to ensure the client's safety are paramount.

Which statement is true about delusional disorder?

Behavior is relatively normal except when focused on the delusion. The course of delusional disorder is variable. The onset can be acute, or the disorder can occur gradually and become chronic. Clients usually live with delusions for years, rarely receiving psychiatric treatment unless their delusion relates to their health (somatic delusion) or they act on the basis of their delusion and violate laws or social rules. Apart from the direct impact of the delusion, psychosocial functioning is not markedly impaired. Behavior is remarkably normal except when the client focuses on the delusion. At that time, the client's thinking, attitudes, and mood may change abruptly. Personality does not usually change, but the client is gradually, progressively involved with the delusional concern.

Which medication is used to control the extrapyramidal effects associated with antipsychotic medications?

Benztropine Benzotropine is an anticholinergic drug used to relieve drug-induced extrapyramidal adverse effects, such as muscle weakness, involuntary muscle movement, pseudoparkinsonism, and tardive dyskinesia.

Which group of theories is believed currently to explain the etiology of schizophrenia?

Biologic Schizophrenia is thought to have multiple etiologies. The overwhelming body of scientific evidence suggests that schizophrenia is a brain disease. Computed tomography scanning and magnetic resonance imaging have shown frequent enlargement of the lateral cerebral ventricles in people with schizophrenia.

Which term is used to describe an activity used to release anger?

Catharsis Catharsis includes activities that provide a release of the anger. Hostility is an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior. Anger is a strong, uncomfortable, emotional response to a real or perceived provocation. Physical aggression is behavior in which a person attacks or injures another person or that involves destruction of property.

A client developed posttraumatic stress disorder (PTSD) after a motor vehicle accident and is scheduled to begin cognitive processing therapy. What outcome should the advanced practice nurse identify when planning this type of therapy?

Client will describe the effects of PTSD on the client's activities of daily living A focus of cognitive processing therapy is identifying the effects of PTSD on daily life. It does not focus directly on stress management techniques or family engagement. Complete control of the fear response is an unrealistic goal of cognitive behavioral therapy.

A psychiatric-mental health nurse is conducting a review class for a group of colleagues about schizoaffective disorder. The nurse determines that the class was successful based on which description of the condition by the group?

Clients are often misdiagnosed as having schizophrenia. Mental health providers find SAD difficult to conceptualize, diagnose, and treat because of the variable clinical course. Clients are often misdiagnosed as having schizophrenia. To be diagnosed with SAD, a client must have an uninterrupted period of illness when there is a major depressive, manic, or mixed episode along with two of the following symptoms of schizophrenia: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, or negative symptoms (e.g., diminished emotional expression, alogia, or avolition). In addition, the positive symptoms (delusions or hallucinations) must be present without the mood symptoms at some time during this period (for at least 2 weeks).

The psychiatric nurse recognizes that a client's cultural background can contribute to the misdiagnosis of schizophrenia primarily for which reason?

Clinicians diagnose culturally accepted beliefs as psychotic thinking Always consider cultural differences when assessing clinical symptoms in clients with suspected psychotic disorders. Ideas that appear delusional in one culture may be acceptable in another; speaking in tongues and visual or auditory hallucinations with religious content are possible examples.

A client spends hours stacking and unstacking towels. The client is repeatedly checking to make sure that the towels are in order of color. What term is used to identify this behavior?

Compulsion Compulsions are ritualistic or repetitive behaviors or mental acts that a person carries out continuously in an attempt to neutralize anxiety. A phobia is an illogical, intense, persistent fear of a specific object or a social situation that causes extreme distress and interferes with normal functioning. An obsession is a recurrent, persistent, intrusive, and unwanted thought, image, or impulse that causes marked anxiety and interference with interpersonal, social, or occupational function. Derealization is sensing that things are not real.

Which are key diagnostic criteria of schizophrenia? Select all that apply.

Continuous signs for at least 6 months One or more major areas of social or occupational functioning markedly below previously achieved levels Delusions present for a significant portion of time during a 1-month period Key diagnostic criteria include continuous signs for at least 6 months, one or more major areas of social or occupational functioning markedly below previously achieved levels, and delusions present for a significant portion of time during a 1-month period. Other criteria include the absence, or insignificant duration, of major depressive, manic, or mixed episodes occurring concurrently with active symptoms and that the disease is not a direct physiologic effect of a substance or medical condition.

When assessing an elderly client who has newly been diagnosed with an anxiety disorder, the mental health nurse's priority is to carry out which task?

Determine the client's risk for self-harm or harm to others The first step in the assessment process is to identify the client's level of anxiety and to determine whether a threat of self-harm or harm to others exists. In any situation where the client history is not known, the nursing priority is safety.

A nurse is assessing a client and determines that the client is experiencing severe anxiety based on which finding?

Distorted sensory awareness In severe anxiety, perception becomes increasingly distorted, sensory input diminishes, and processing of sensory stimuli becomes scattered and disorganized.

The nurse is developing a care plan for a client with somatic delusions. Which would be an appropriate nursing diagnosis for this client?

Disturbed thought process The most appropriate nursing diagnosis for this client is disturbed thought process related to misperception of environmental stimuli. Disturbed sleep pattern, risk for self-directed violence, and chronic low self-esteem would not be the most appropriate nursing diagnosis for this client.

A group of nursing students is reviewing the various theories related to the etiology of schizophrenia. The students demonstrate understanding of the information when they identify which neurotransmitter as being responsible for hallucinations and delusions?

Dopamine Although research is demonstrating that schizophrenia does not result from dysregulation of a single neurotransmitter or biogenic amine (such as serotonin, norepinephrine, or dopamine), positive symptoms of schizophrenia, specifically hallucinations and delusions, are thought to be caused by dopamine hyperactivity in the mesolimbic tract. Researchers are also hypothesizing a role for GABA but have yet to identify any specific information.

What interventions does the nurse perform when caring for a client with obsessive-compulsive disorder (OCD)? Select all that apply.

Encourage the client to perform activities of daily living within a fixed time. Teach the client social skills such as appropriate conversation topics. Teach the client to avoid trigger situations. Nursing interventions for OCD include encouraging the client to perform activities of daily living within a fixed time, teaching the client social skills such as appropriate conversation topics, and teaching the client to avoid trigger situations. The nurse should not provide undue praise, such as rewarding the client for every activity. Clients with OCD benefit from genuine praise that is earned. The nurse should convey interest when speaking to the client; however, a calm, reassuring voice is not necessary. This tone is used with clients experiencing a panic attack.

The nurse is assessing a client with schizophrenia who has a history of successfully managing the symptoms. The client has few social activities and speaks in a flat tone when interacting with others. Currently the client is experiencing acute psychosis with active hallucinations and social withdrawal. The nurse identifies improved social skills as an important therapeutic goal. How should the nurse implement this plan?

Enter the client in a social skills training program when acute psychosis subsides. Although severe psychotic symptoms of schizophrenia can subside with pharmacologic treatment, many clients still have severely restricted social lives. Impaired communication, lack of motivation, inattention to self-care, and difficulty establishing and maintaining relationships leave them socially isolated. Psychosocial approaches can help clients improve social functioning and enjoy a better quality of life. These interventions usually are not implemented, however, until psychotic symptoms are controlled.

The nurse suspects that a client is experiencing a brief psychotic episode based on what? Select all that apply.

Evidence of hallucinations Intense changes in affect Recent life stressor In brief psychotic disorder, the length of the episode is at least 1 day but less than 1 month. The onset is sudden and includes at least one of the positive symptoms of criteria A for schizophrenia (delusions or hallucinations). The person generally experiences overwhelming confusion and rapid, intense shifts of affect. Brief psychotic disorder can often occur in the context of a recent life stressor such as giving birth.

The nurse is caring for a client with dermatillomania. What symptoms of this disorder does the nurse recognize in this client?

Excoriation of the skin The client with dermatillomania attempts to reduce anxiety by picking on the skin. This client has excoriated skin. Trichotillomania is a disorder which causes the client to repeatedly pull the hair to reduce anxiety. The client with onychophagia is likely to have very short nails due to frequent nail biting. Frequent and ritualistic hand washing is an obsessive compulsive disorder leading to dry, cracked hands.

When lecturing about dissociative disorders to a group of nursing students, a nurse states that an essential feature of these disorders involves what?

Failure to integrate identity, memory, and consciousness The essential feature of these disorders involves a failure to integrate identity, memory, and consciousness. That is, unwanted intrusive thoughts disrupt one's contact with the here and now, or memories that are normally accessible are lost. These disorders are closely related to trauma- and stressor-related disorders but are categorized separately.

Which medication does the nurse anticipate the health care provider will prescribe for a client who is beginning treatment for obsessive-compulsive disorder (OCD)?

Fluvoxamine The client who is beginning treatment for OCD is prescribed the selective serotonin reuptake inhibitor depressant fluvoxamine as a first-line choice. Clients with treatment-resistant OCD may respond to second-generation antipsychotics such as risperidone, quetiapine, and olanzapine.

During an admission assessment, a client with schizoaffective disorder states that the client hears the voice of God in the client's head and the voice is telling the client that the client is worthless. What would the nurse document this symptom as?

Hallucination Hallucinations are sensory perceptions with a compelling sense of reality but with no actual objective basis. During auditory hallucinations (the most common form), clients may hear the voice of God or close relatives, two or more voices with a running commentary about the client's behavior, or voices that command certain acts. Delusions are false, fixed beliefs. Avolition involves the withdrawal and inability to initiate and persist in goal-directed activity. Alogia refers to the reduced fluency and productivity of thought and speech.

Clients diagnosed with schizophrenia may experience disordered water balance that may lead to water intoxication. Which may occur as a result of water intoxication?

Hyponatremia Hyponatremia is a life-threatening complication of unknown cause. When a client ingests an unusually large volume of water, the kidneys' capacity to excrete water is overwhelmed, and serum sodium concentrations rapidly fall below the normal range.

Catatonia as seen in clients with schizophrenia is unique in the existence of which feature?

Immobility like being in a trance Catatonia, as seen in clients with schizophrenia, is a psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless as if in a trance.

Which is one characteristic that differentiates generalized anxiety disorder (GAD) and panic disorder?

In GAD, the person usually does not experience eruptions of acute anxiety. GAD is characterized by the pervasive existence of severe anxiety with no apparent cause. Panic disorder is characterized by acute onset of panic levels of anxiety.

Positive symptoms seen in schizophrenia are believed to be a result of which type of neurological dysfunction?

Increased amount of dopamine Positive (or productive) symptoms reflect an increased amount of dopamine affecting the cortical areas of the brain. Negative symptoms reflect an inadequate amount of dopamine, cerebral atrophy, and organic functional changes in the brain.

A client with schizophrenia is exhibiting emotional withdrawal and poor eye contact. The mental health nurse knows that these symptoms are suggestive of which neurotransmitter imbalance?

Increased serotonin and dopamine Negative symptoms are thought to be due to cerebral atrophy, an inadequate amount of dopamine and serotonin, or other organic functions in the brain.

A group of nursing students is reviewing information about the types of abuse. The students demonstrate understanding of the information when they identify stalking as a crime of which of the following?

Intimidation Stalking is a crime of intimidation in which stalkers harass and terrorize their victims through behavior that causes fear or substantial emotional distress. Rape is a crime of violence.

Which state allows for an insanity defense?

Iowa Iowa has not abolished the insanity defense. Idaho, Montana, and Utah have abolished this defense.

The partner of a client with obsessive-compulsive disorder (OCD) reports that the client regularly exhibits "strange behaviors." What does the nurse tell the partner about these behaviors? Select all that apply

It is an attempt by the client to overcome anxiety. It is associated with an irrational persistent thought. The client will repeat the act several times during the day. The behavior exhibited by the client with OCD is an attempt to overcome anxiety. Irrational, persistent thoughts stimulate the client to repeat the act several times during the day. The client is aware that the thoughts are unreasonable but is compelled to perform them to alleviate anxiety. It is not a degenerative disorder because there is no organic cause for the behavior.

The partner of a client with obsessive-compulsive disorder (OCD) reports that the client regularly exhibits "strange behaviors." What does the nurse tell the partner about these behaviors? Select all that apply.

It is an attempt by the client to overcome anxiety. It is associated with an irrational persistent thought. The client will repeat the act several times during the day. The behavior exhibited by the client with OCD is an attempt to overcome anxiety. Irrational, persistent thoughts stimulate the client to repeat the act several times during the day. The client is aware that the thoughts are unreasonable but is compelled to perform them to alleviate anxiety. It is not a degenerative disorder because there is no organic cause for the behavior.

A client states that the client copes with anxiety by cleaning compulsively, which irritates the client's spouse. What does the nurse consider this?

Maladaptive, because it is an avoidance response Clients learn to reduce the anxiety they feel in either functional or dysfunctional ways. Functional responses tend to be voluntary, conscious behaviors that address and acknowledge the stressful situation and help clients to find solutions. Dysfunctional responses tend to be involuntary, inflexible, avoidance-type solutions that impair productivity. The nurse should not ask the client to give up coping mechanisms, even maladaptive ones, without offering other adaptive mechanisms. In other words, it is not appropriate to expect a client to just stop worrying, compulsively checking doors, or otherwise trying to cope with anxiety.

A group of nursing students is reviewing information about intimate partner violence (IPV). The group demonstrates understanding of this topic when they identify which of the following?

Men may not consider behaviors such as slapping or shoving as abuse. Men are sometimes hesitant to report victimization or may not consider behaviors such as shoving or slapping "abuse." Nearly one in four women and one in nine men are victims of IPV at some point in their lives. Women are much more likely than men to be seriously injured as a result of IPV and to require medical treatment. IPV in same-sex couples occurs with at least the same frequency as in heterosexual relationships, but individuals with same-sex partners may not be afforded the same support. The reaction to IPV may differ by gender.

The mental health nurse is gathering a health history on a new client. The client is constantly pacing the floor and is concerned only with stating that the client is about to die. The nurse would classify this level of anxiety as what?

Moderate In moderate anxiety, the client experiences a narrowing of the ability to concentrate. The client paces, has voice tremors, and has an increased rate of speech. During euphoria, the client experiences an exaggerated feeling of well-being that is not directly proportional to a specific circumstance or situation. Mild anxiety causes the client to have an increased alertness to inner feelings or the environment. During severe anxiety, the client is able to focus on only small or scattered details.

The nurse must be aware that individuals from diverse ethnic groups might describe troubling experiences in terms of physical problems or specific culture-bound syndromes. The syndrome of ghost sickness is exhibited by which culture?

Native American The culture-bound syndrome of ghost sickness is seen in the Native American tribal culture. This culture exhibits a preoccupation with death and the deceased. Bad dreams, weakness, feelings of danger, anxiety, and hallucinations may occur. The other options are not related to the culture-bound syndrome of ghost sickness.

Which should the nurse anticipate when providing therapy and evaluating outcomes for a client with delusional disorder?

Often not met completely In evaluating progress, the nurse must remember that outcomes are often not met completely.

The nurse can document correctly that a client diagnosed with an anxiety disorder is experiencing moderate anxiety when the nurse observes the client doing what?

Pacing and repeatedly asking staff what time the "doctor will be here." The nurse documents that a client diagnosed with an anxiety disorder is experiencing moderate anxiety when the nurse observes the client pacing and repeatedly asking staff members when the doctor will arrive. Moderate anxiety is characterized by wandering attention. The client may require repeated redirection, such as in this scenario.

The nurse has read in a client's admission record that the client has been taking propranolol for psychiatric, rather than medical, reasons. The nurse should recognize that the client likely has a history of which mental health condition?

Panic disorder Propranolol is used in the treatment of panic disorder, but it is not a common pharmacological intervention for OCD, acute stress disorder, or nightmares.

A client with obsessive-compulsive disorder (OCD) has been assessed by the primary care provider. What treatment is most likely?

Paroxetine Paroxetine is a sustained serotonin reuptake inhibitor (SSRI). SSRIs are a first line treatment for OCD. Phenelzine is a monoamine oxidase inhibitor and olanzapine is an antipsychotic; neither are commonly used to treat OCD. Benzodiazepines such as lorazepam are not normally used.

When caring for a client who is experiencing the symptomology of acute stress disorder, the nurse recognizes the importance of minimizing the client's risk for developing which condition?

Posttraumatic stress disorder When caring for a client who is experiencing the symptomology of acute stress disorder, the nurse recognizes the importance of minimizing the client's risk for developing posttraumatic stress disorder, not emotional numbness, dissociative amnesia, or paranoia.

What relaxation technique does the nurse teach the client with obsessive-compulsive disorder (OCD)?

Practicing deep breathing The nurse teaches the client deep breathing for relaxation. The nurse encourages the client to practice deep breathing when anxiety increases. The client is taught to maintain a diary to note down situations that trigger obsessions. The nurse sets a timetable for the client's daily routine. This helps to ensure that the client completes tasks within a scheduled time. The effect of music on clients with OCD is not known.

The psychiatric mental health nurse has received a referral from a community health nurse regarding a client who appears to have hoarding disorder. When planning this client's care, the nurse should prioritize what consideration?

Promoting the client's safety in the home environment Safety is a paramount consideration for clients with hoarding disorder. Clients are not normally open to differentiating between necessary and unnecessary items. Relaxation techniques are secondary to safety and there is not normally a need to involve law enforcement.

A nurse is providing care to several clients with obsessive-compulsive disorder. Which client would the nurse identify as most likely to benefit from psychosurgery?

Psychosurgery is an option for severe OCD but is not typically used for the treatment of trichotillomania, hoarding, or skin-picking disorder. Psychosurgery is an option for severe OCD but is not typically used for the treatment of trichotillomania, hoarding, or skin-picking disorder. Psychosurgery is reserved for clients whose OCD is extremely severe and which has not responded to conservative treatment.

After teaching a class on antipsychotic agents, the instructor determines that the education was successful when the class identifies which as an example of a second-generation antipsychotic agent?

Quetiapine Quetiapine is an example of a second-generation antipsychotic agent. Fluphenazine, thiothixene, and chlorpromazine are examples of first-generation antipsychotic agents.

Which statement requires additional education regarding the truth about rape?

Rape is a crime of passion. Rape is a crime of violence and humiliation of the victim expressed through sexual means. The remaining options present accurate information about the act of rape so no further education or correction is needed.

A client with schizoaffective disorder (SAD) is prescribed clozapine. The nurse understands that in addition to the drug's antipsychotic effects, it is also effective in which area?

Reducing the risk for suicide Clozapine, reported effective for SAD by several authorities, can reduce hospitalizations and risk for suicide. The risk for extrapyramidal effects is not reduced or limited. Additional agents may be necessary based on the client's symptoms. Client's prescribed clozapine must be have regular bloodwork monitoring for the risk of agranulocytosis. There is a high risk for cardiac issues such as tachycardia, which also require physiologic monitoring.

A client has been prescribed clozapine for schizoaffective disorder (SCA) with depression. The nurse should explain to the client that one advantage of clozapine is that it can provide what?

Reduction of hospitalizations and risk for suicide Clozapine, reported effective for SCA by several authorities, can reduce hospitalizations and risk for suicide. A significant portion of clients whose symptoms have resisted other neuroleptic agents improve on clozapine.

A client with PTSD is brought to the nurse in a primary care setting with lower back pain after falling from a ladder. The client became aggressive with their partner before agreeing to come to the setting. The nurse smells alcohol on the person's breath and the client does not make eye contact or expand openly to assessment questions. Which are priority nursing assessments? Select all that apply.

Risk for self-injury Risk for aggression Risk for substance abuse PTSD is associated with increased risk of suicide, aggression and substance abuse. Assessment for sexual dysfunction or body image issues would not be a priority in this situation where the client with PTSD has sustained a fall, there is likelihood he was drinking alcohol and there has been a history of aggression.

A client with schizophrenia is exhibiting positive and negative symptoms. The nurse anticipates that the client would be prescribed what?

Second generation antipsychotic The second-generation antipsychotics are effective in treating negative and positive symptoms. These newer drugs also affect several other neurotransmitter systems, including serotonin. This is believed to contribute to their antipsychotic effectiveness. None of the other agents would be appropriate.

Which medication classification has been used to treat social phobia?

Selective serotonin reuptake inhibitors (SSRIs) SSRIs are used to treat clients with social phobia because they significantly reduce social anxiety and phobic avoidance. Benzodiazepines are also used to reduce anxiety caused by phobias.

A client spends an hour cleaning and rearranging the client's desk prior to starting work after every break. This occurs about five to six times a day. How does the nurse rate the client according to the Yale-Brown Obsessive Compulsive Scale?

Severe The nurse records severe OCD for the client who spends greater than 3 and up to 8 hours/day performing compulsions. The client loses several productive hours during the day. The client with mild traits of OCD spends less than an hour per day in ritualistic behavior. The client who spends 1 to 3 hours in repetitive behavior every day is said to have moderate OCD. Extreme OCD causes a person to spend more than 8 hours a day performing compulsions.

A 3-year-old who has been seen in the emergency department for various fall-related injuries is being treated for apparent blindness in the left eye as a result of retinal hemorrhage. The nurse should suspect that which form of child abuse is part of the cause of the child's condition?

Shaken baby syndrome Despite its name, shaken baby syndrome has been documented in children up to 5 years of age. The physical findings usually include bruising from being grabbed firmly along with major head injury, such as subdural hematoma or cerebral edema. Nonfatal consequences include blindness due to retinal hemorrhage.

A client diagnosed with delusional disorder who uses excessive health care resources most likely has which type of delusions?

Somatic Persons who have somatic delusions believe they have a physical ailment. Clients with somatic delusions use excessive health care resources. The central theme of the jealous subtype is the unfaithfulness or infidelity of a spouse or lover. Nihilistic delusions focus on death or calamity. Clients presenting with grandiose delusions are convinced they have a great, unrecognized talent or have made an important discovery; a less common presentation is the delusion of a special relationship with a prominent person or actually being a prominent person.

Which is a pattern of repeated unwanted contact, attention, and harassment that often increases in frequency?

Stalking Stalking is a pattern of repeated unwanted contact, attention, and harassment that often increases in frequency. Stalking is a crime of intimidation. Rape is the penetration of any bodily orifice by the penis, fingers, or an object. Incest involves sexual contact between family members. Physical abuse involves bodily harm.

A 55-year-old client was admitted to the psychiatric unit after an incident in a department store in which the client accused a sales clerk of following the client around the store and stealing the client's keys. The client was subdued by the police after destroying a window display because voices had told the client that it was evil. As the nurse approached the client, the client says, "You're all out to get me, and you're one of them. They're Rostoputians and grog babies here." This demonstrates what?

Suspiciousness and neologisms The client is demonstrating suspiciousness ("you're all out to get me") and neologisms (use of the words "Rostoputians and grog babies"). Loose associations and flight of ideas occur when the client talks about many topics in rapid sequence, but they are not connected with each other. Illusions are when the client sees something that is not there; echolalia is the repetition of words (or words that sound similar) said by someone else.

A nurse is assessing a client and suspects obsessive-compulsive disorder .The nurse understands that to rule a behavior as obsessive-compulsive disorder (OCD), the obsession or compulsion must meet which criteria?

Take up more than 1 hour/day and cause stress to the client. OCD is diagnosed when recurrent obsessions or compulsions (or both) take up more than 1 hour a day or cause considerable stress to the individual. These obsessions or compulsions are not caused by substance or medication use or other disorders. Some individuals recognize that these obsessions or compulsions are excessive and unrealistic; others have limited insight and are unsure whether the obsessive thoughts are true but continue to have the thoughts and feel compelled to perform the actions. Another group of individuals are convinced that their obsessive thoughts are true. These thoughts and compulsive behaviors are stressful and interfere with normal daily routines.

The nurse is assessing a client who performs ritualistic counting of objects in the client's surroundings. What does the nurse tell the client about obsessive-compulsive disorder and its treatment? Select all that apply.

Talk openly with the nurse about obsessions, compulsions, and anxiety. Do not skip medication; it is an important part of the treatment. Learn and practice deep breathing and guided imagery. Treatment includes openly discussing all the obsessions, compulsions, and anxiety with nursing staff to help develop a plan of care. The client will be requried to take prescribed medication and to participate in behavior therapy to gradually eliminate the disorder. Treatment will also include learning deep breathing and guided imagery, which the client should practice and use for relaxation when anxiety levels increase. The client will be encouraged to share all concerns about the disorder with the family to eliminate the guilt of secrecy. The client will learn to tolerate anxiety as a part of the treatment to eliminate irrational behavior. Tolerating anxiety is not harmful to health and well-being.

A client with obsessive-compulsive disorder (OCD) states making a concerted effort to reduce the frequency and duration of rituals. What intervention should the nurse include to assist in these efforts?

Teach the client nonpharmacologic relaxation techniques Reducing the frequency of rituals for a person with OCD causes anxiety. Clients consequently benefit from learning techniques that can reduce their stress in a healthy way. Mood stabilizers are not typically used in the treatment of OCD, and nurses do not normally facilitate the performance of rituals. The client is likely aware of the negative consequences of obsessions and rituals, as evidence by efforts to eliminate them.

The psychiatric-mental health nurse is providing care for a child who has been diagnosed with disinhibited social engagement disorder. What intervention best addresses the characteristics of this disorder?

Teaching the child how to interact appropriately with strangers Disinhibited social engagement disorder is characterized by being overly familiar with strangers. The disorder is not primarily associated with family boundaries, disruptive thoughts, or the management of conflict.

The nurse is educating the client's family about compulsive behavior. The nurse is correct when making which statement?

The behavior neutralizes anxiety caused by obsessive thoughts. The client attempts to suppress or ignore the intrusive thoughts by indulging in ritualistic behavior. This behavior neutralizes the anxiety caused by obsessive thoughts. However, the thoughts and behaviors are not realistically connected. The client becomes agitated and anxiety levels increase when prompted to stop by external stimuli. The client has normal intellectual functioning and is not on the verge of insanity.

The nurse is evaluating the plan of care for a client with schizophrenia. Which observation bestsuggests that the plan has been effective?

The client has resumed employment and attends social functions. Major goals for the care of a client with schizophrenia are to experience improved thought processes and fewer psychotic symptoms, to not engage in violent behavior, to acquire improved social skills and engage in satisfying social interaction, and to gain knowledge about the disease process and treatment. Increased conversations with the staff is unrelated to the overall plan of care for the client with schizophrenia.

A nurse assesses a client and determines that the client is experiencing mild anxiety based on what?

The client is aware and alert A client who is mildly anxious is aware, alert, sees, hears, and grasps more than before. Selective inattention reflects moderate anxiety. Focusing attention on a small area reflects severe anxiety. Feelings of unreality are associated with panic.

The nurse is assessing a client with anxiety. Which behavior might indicate that the client has moderate anxiety?

The client is nervous and agitated. A client who is moderately anxious has a disturbing feeling that something is wrong. This causes nervousness and agitation. Increased concentration and attention is seen in clients having mild anxiety. Cognitive skills are impaired in clients who have severe anxiety. Inability to communicate verbally indicates that the client is panicking.

Which factor has the least influence on achieving mental health for the client who has anxiety disorder?

The client is often late to school and makes poor grades in most of the client's subjects. Being late to school and making poor grades are behaviors that indicate that the client is having difficulty; they are not factors influencing the development of the client's anxiety disorder.

A client is late for work every day because the client spends about 20 minutes checking and rechecking the lights and water taps before leaving home. What kind of behavior does the nurse understand is exhibited by the client?

The client is trying to reduce anxiety by repeating specific tasks. The client's repeated checking rituals are affecting daily functioning. This behavior is a distinctive trait of obsessive-compulsive disorder. This self-soothing behavior helps to overcome anxiety. The client is unable to control the urge to repeatedly check the house before leaving. A client who is particular about resource management does not waste time in unproductive work. The client is not intentionally reporting late to work or seeking attention.

A client with obsessive-compulsive disorder (OCD) spends several hours each day cleansing the home and washing the hands. The client tells the nurse, "I don't think you quite realize how many bacteria, viruses, and fungi live around us." What is the nurse's most accurate interpretation of this client's statement?

The client may lack insight into the OCD The client's statement is an attempt to present a rational justification for the client's actions. This suggests a lack of insight. There is no particular association between this client's statement and physiologic factors. A lack of insight is a challenge for treatment, but it does not necessarily mean that the client will be unresponsive to treatment. Rituals often have no direct relationship with a specific event in the past.

The nurse is assessing a client who habitually counts the number of objects in the client's surroundings. What finding does the nurse identify with obsessive-compulsive disorder (OCD)? Select all that apply.

The client repeatedly counts objects several times in a day. The client develops anxiety if the count ends with an odd number. The client avoids an interview in an office situated on the ninth floor. The client's mother rearranges objects around the house several times a day. The client with OCD performs ritualistic behaviors such as counting. The client may count books, stairs, or similar-looking items in the surroundings. The client repeatedly counts until an even number is obtained to soothe feelings of anxiety. The client's behavior is interfering with the client's functioning. The client missed an opportunity for progress by avoiding an interview. OCD is found to run in families. Inherited genetic factors are known to influence a person's thoughts. An individual's passion for numbers does not indicate presence of OCD in the client.

A client with a history of angry outbursts that have caused interpersonal and work problems has been in counseling for several months. The nurse judges the plan of care to be effective when which outcome is met?

The client uses adaptive coping to manage anger impulses. Overall goals for aggressive or violent clients are to refrain from threatening or harming anyone during episodes of anger. Using adaptive coping to manage angry impulses indicates the client has gained insight into and skill at managing aggressive impulses. Although gaining insight into situations that trigger anger, increasing self esteem, and reporting increased feelings of self-control are critical elements in working toward effective management of anger, the goal of treatment is achieved when the client can put what he or she has learned into action.

A nurse is caring for a client who has panic attack. The nurse takes the client in a small, isolated room. How would this intervention benefit the client? Choose the best answer.

The client would have an enhanced sense of security. A client with panic-level anxiety should be taken to a small, isolated room. This is to reduce any external stimuli that could escalate anxiety. Taking the client to a small room would make the client feel more protected and secured. A client experiencing a panic attack may lose rational thought; however, this intervention would not directly improve thought processes. The client would not be able to demonstrate relaxation techniques in a panic laden state. This intervention would not enhance the client's ability to understand what the nurse is saying.

A client's estranged spouse has phoned the hospital unit several times seeking information about the client's admission and status. A nurse hears a colleague tell the client, "No, your spouse has not called as far as I know." When confronted by the nurse, the colleague states, "I'm just trying to look out for the client by protecting the client from stress." How should the colleague's actions be interpreted?

The colleague had good motives but violated the principle of veracity Deception violates veracity, even if it is motivated by the client's interests. This deception would not be considered to be a justifiable example of paternalism. Fidelity focuses on obligations and duties. The colleague neglected the client's autonomy rather than promoting it.

A client with a psychiatric illness has become extremely aggressive and the nurse decides that the client needs to be restrained. Which action would be considered human restraint?

The nurse and a group of paramedics hold the client. Restraint is the direct application of physical force to restrict the client's freedom of movement. The nurse and a group of paramedics holding the client is an example of human restraint. The nurse does not apply force while telling the client to calm down. Sedating the client is an example of chemical restraint. Applying a wrist cuff to control the aggression of the client indicates the use of mechanical restraints.

What does the nurse find on assessment of the thought processes of a client with obsessive-compulsive disorder (OCD)?

The obsessions become intense as the client tries to stop the behavior. Clients with OCD do not willingly have obsessions or images, and their obsessions become more intense when they try to prevent them. Clients with OCD do not experience effects in memory or intellectual functioning. However, they have difficulty concentrating when the obsessions are strong. For most, the obsessions arise out of nowhere, during other activities.

Which would be the benefit of including a client's family members in the long-term treatment of a client with schizophrenia?

The onset of a possible relapse can be detected early and effective treatment can be initiated Family education can help family members deal more effectively with a loved one who has schizohprenia, enabling them to contribute to a better outcome for the client, especially because they may be more able to recognize relapse.

A psychiatric-mental health nurse is teaching a class about schizophrenia. When describing delusions, which information would the nurse most likely include?

They could be a real-life situation. Delusions are fixed, false beliefs that cannot be changed by conflicting evidence. They can be situations that could occur in real life and are plausible in the context of the person's ethnic and cultural background, or clearly impossible. They usually involve a misinterpretation of experience.

When assessing a client with a delusional disorder who is experiencing somatic delusions, which would the nurse expect as within normal parameters? Select all that apply.

Thinking Orientation Attention In clients with delusional disorders, mental status is not generally affected. Thinking, orientation, affect, attention, memory, perception, and personality are generally intact. Most clients who receive diagnoses of delusional disorder do not experience functional difficulties or impairments. Self-care patterns may be disrupted in clients with the somatic subtype by the elaborate processes used to treat perceived illness (e.g., bathing rituals, creams). Sleep may be disrupted because of the central and overpowering nature of the delusions.

The nurse is assessing a teenage client with onychophagia. What does the nurse teach the parent about the disorder?

Treatment with selective serotonin reuptake inhibitor (SSRI) antidepressants is effective. SSRI depressants are found to be effective in the treatment of onychophagia or nail biting disorder. The typical onset of the disorder is in childhood with a decrease in behavior by age 18. It is a self-soothing behavior. It cannot be classified as a generalized anxiety disorder. It is known to be an obsessive-compulsive disorder. The client bites the nails to overcome anxiety caused by obsessions.

What intervention does the nurse implement to enable the client with repetitive behavior to complete daily activities?

Verbally direct the client during the activity. The nurse talks and guides the client throughout the activity to prevent the client from being distracted by anxious thoughts. Telling the client to take as much time as is needed to complete the task gives the client permission to engage in maladaptive rituals to neutralize anxiety rather than work at developing healthier coping through the use of exposure and response therapy. The client may not be able to estimate the amount of time a normal person would need to complete the given task. The nurse does not try to limit stimuli that activate repetitive behavior. The client must learn to overcome these stresses during behavior therapy. The family does not participate in the activity but the nurse teaches the family about the illness and methods of treatment.

A client diagnosed with schizophrenia states, "I want to go home, go home, go home." This is an example of which speech pattern?

Verbigeration A verbigeration is the stereotyped repetition of words or phrases that may or may not have meaning to the listener. Clang associations are ideas that are related to one another based on sound or rhyming rather than meaning. Neologisms are words invented by the client. A word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener.

A nurse is contributing to the interdisciplinary care plan for a client who has been diagnosed with PTSD. Which should be included in the care plan?

Vigilant monitoring for potential indications of self-harm The risk for suicide or other forms of self-harm is high in clients with PTSD. MAOIs are not used to treat the disorder, and delusions and hallucinations rarely occur. Social isolation is common among patients with PTSD; inappropriate social interactions, however, are less common.

A nurse is teaching a client about how traumatic events affect a person. Which examples are included in the teaching plan? Select all that apply

Witnessing a fatal shooting Being trapped inside a capsized boat Receiving word of a terrorist attack in a nearby community Traumatic events are those that are experienced, observed, heard about or that involve repeated exposure to adverse events. Witnessing a fatal shooting, being inside a capsized boat or hearing about a nearby terrorist attack are all traumatic events. Having regular family responsibilities is not considered to be traumatic. Culturally based experiences are not considered to be traumatic events.

A group of students is reviewing information about anxiety disorders in preparation for a class examination. The students demonstrate understanding of the material when they state what?

Women experience anxiety disorders more often than do men. Women experience anxiety disorders more often than do men by a 2-to-1 ratio. Anxiety disorders are the most common of the psychiatric illnesses treated by health care providers. They tend to be chronic and persistent illnesses with full recovery more likely among those who do not have other mental or physical illnesses. Anxiety disorders are the most common condition of adolescents, with one in three having an anxiety disorder.

Which nursing intervention is focused on the primary goal of anxiety management and treatment?

assessing the client's ability to implement stress management techniques effectively For people with anxiety disorders, it is important to emphasize that the goal is effective management of stress and anxiety, not the total elimination of anxiety. Learning anxiety management techniques and effective methods for coping with life and its stresses is essential for overall improvement in life quality. Although medication is important to relieve excessive anxiety, it does not solve or eliminate the problem entirely. While assessment is appropriate, it is not directly associated with the management and treatment of the original disorder.

A middle-aged client with young children has been the victim of intimate partner violence (IPV). When providing initial care to this family, the nurse should:

carefully assess the children for signs of trauma. Children are inevitable victims in an IPV situation and must be assessed and cared for accordingly. The nurse must avoid false reassurance. It is unnecessary, and often impossible, to identify specific causes for IPV. Relationship skills can be addressed in follow-up care.

A nursing instructor is preparing a class lecture about schizophrenia and outcomes focusing on recovery. Which would the instructor include as a major goal?

continuity of care Outcome research has shown that schizophrenia can be successfully treated and managed. Continuity of care has been identified as a major goal of recovery for clients with schizophrenia because they are at risk for becoming lost to services if left alone after discharge. Although inpatient hospitalizations that are brief and focus on client stabilization, crisis management as key to emergency care, and decreased social isolation through social engagement are all important, they are not considered major goals for recovery.

A client has experienced a physcial assault and states "I keep having nightmares about it." Which intervention may be most helpful for the nurse to explore with the client at this time?

debriefing about the event The client who has experienced a traumatic event such as a physical assault may benefit from debriefing which involves the client reconstructing the event. While exercise may be beneficial in general, it is not a specific treatment related to a traumatic event. It is premature to plan prescription of a sleep aid or hospitalization before trying other measures with debriefing or counseling

A nurse is seeing a client who is having severe to panic level anxiety after a physical assault months previously. The client tells the nurse, "When the panic starts I feel like I am watching myself through a window." The nurse can most accurately describe this experience as:

depersonalization. Depersonalization is a feeling that the client may describe as being disconnected from herself, such as watching oneself. This is common when individuals experience panic levels of anxiety. Derealization refers to the sensation that things are not real or surreal during panic levels of anxiety. Decatastrophizing refers to a treatment approach used by therapists in which the client is asked questions in order to urge the client to develop a more realistic appraisal of the situation causing the anxiety. Automatisms are automatic, unconscious mannerisms that are geared toward relief of anxiety and increase in intensity and frequency with a rise in the client's anxiety level.

When assessing a person with delusional disorder, which finding would the nurse expect to assess?

few, if any, psychological deficits Clients with delusional disorder show few, if any, psychological deficits. In these clients, average or marginally low intelligence is characteristic. Mental status is not generally affected. Thinking, orientation, affect, attention, memory, perception, and personality are generally intact.

The nurse is orienting a new staff member in an inpatient mental health unit when a client begins to act in a violent manner. The nurse should explain to the new staff member that some clients use violence and aggression to ...

have their needs met. The nurse should explain to the new staff member that some clients use violence and aggression to get what they want or to force change or regain control. The client may also be seeking attention.

A client with schizophrenia is prescribed clozapine. The nurse would monitor the client closely for specific signs of:

infection. Agranulocytosis can develop with the use of all antipsychotic drugs, but it is most likely to develop with clozapine use. Therefore, the nurse needs to be alert for signs of infection, particularly bacterial infection. Hypotension may occur with any antipsychotic drug. Nausea is a common side effect of many drugs. Weight gain, not loss, can occur with olanzapine and clozapine.

The client just received a diagnosis of end-stage renal disease. After hearing options, the client visited a lawyer and documented what treatment is to be held in the event that the client is unable to make decisions. The nurse asks for a copy of this document for the chart. The name of this document is:

living will A living will states what treatment should be omitted or refused in the event that a person is unable to make those decisions. Informed consent is the permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits. Patient rights are those basic rules of conduct between patients and medical caregivers as well as the institutions and people that support them. A durable power of attorney means that the document stays in effect if you become incapacitated and unable to handle matters on your own.

While caring for a hospitalized client with schizophrenia, a nurse observes that the client is listening to the radio. The client tells the nurse that the radio commentator is speaking directly to the client. The nurse interprets this finding as:

referential thinking. The client is exhibiting referential thinking, that is, the belief that neutral stimuli, such as the radio, have special meaning to that person, such that the radio commentator is talking directly to him. Autistic thinking involves restriction of thinking to the literal and immediate so that the individual has private rules of logic and reasoning that make no sense to anyone else. Concrete thinking reflects a lack of abstraction in thinking with the inability to understand punch lines, metaphors, and analogies. Illusional thinking occurs when a person misperceives or exaggerates stimuli that actually exist in the external environment.

A nurse is caring for a client who has been receiving treatment for schizophrenia with chlorpromazine for the past year. It would be essential for the nurse to monitor the client for:

tardive dyskinesia. Tardive dyskinesia is late-appearing, abnormal involuntary movements. Therefore, it is essential that the nurse monitor the client for tardive dyskinesia at this time. Weight gain (not weight loss) and new onset of diabetes (hyperglycemia) are possible side effects of an antipsychotic. Torticollis, a dystonic reaction, would occur early in antipsychotic drug treatment.

The nurse is assessing a client who has recently received a diagnosis of posttraumatic stress disorder. When conducting this assessment, the nurse should:

try to identify any strengths or skills that can be applied during recovery. During assessment, it is important to note any strengths that can be integrated into the client's care. Psychological findings do not always take priority over physical findings and it is unnecessary to confirm everything that the client says with another individual. The nurse must avoid false reassurance; full recovery is never guaranteed.

A client is attending anger management class and wants to know how the class will help. What is the nurse's best response?

"It will help you to learn how to control the arousal of anger." It is unrealistic for someone to stop feeling angry altogether; however, the goal of anger management therapy can help a client learn how to control the arousal of anger. Anger management therapy is not utilized for clients who are violent when angry because it has not been found to be effective in modifying violent behavior.

A nurse is assessing a client in a community clinic who reports feeling anxious lately because she is considering leaving her marriage. The client describes a long history of partner abuse associated with this relationship. How should the nurse respond to this client?

"You have the right to be safe and respected." When working with someone who is a victim of partner abuse, it is important that the nurse assertively support the client's decision. The affirmation of the client's decision can help to improve the client's self-confidence as she begin the process of leaving her partner. It is important the nurse refrain from recommending couple's counseling, imply doubt about the client's situation, or take charge and do everything for the client.

A client is currently experiencing panic. Which action would be most appropriate for the nurse to do?

Allow the client to pace With panic, the nurse should stay with the client. Allow pacing and walk with the client. No content inputs to the client's thinking should be made by the nurse. Asking repeated questions and teaching would be inappropriate because the client is already over-stressed. The client should use positive self-talk. Encouraging vigorous exercise would increase the physiological arousal associated with panic and should be avoided until the client is calm. Exercise should be encouraged for prevention and to promote mental wellness.

A client was admitted for electroconvulsive therapy (ECT). The physician performing the procedure failed to obtain informed consent before the ECT was administered. The physician could be charged with what?

Battery All clients have the right to give informed consent before health care professionals perform interventions. Administration of treatments or procedures without a client's informed consent can result in legal action against the primary provider and the health care agency. In such lawsuits, clients will prevail, alleging battery (touching another without permission), if they can prove they did not consent to the procedure, providers did not give adequate information for a decision, or the treatment exceeded the scope of the consent.

When noted in an assessment of a child, the nurse should suspect child abuse if which common physical findings signaling abuse are present?

Bruises, burns, lacerations, missing teeth, and skeletal injuries The most common indicators of physical abuse of a child are as follows: (1) bruises involving no breaks in skin integrity, (2) burns, usually due to immersion in hot water, contact with cigarettes, tying with a rope, or the application of a hot iron, (3) lacerations, abrasions, welts, and scars noted on the lips, eyes, face, and external genitalia, (4) missing or loosened teeth, and (5) skeletal injuries such as fractured bones, epiphyseal separation, or stiff, swollen, enlarged joints.

A nurse is assessing a Haitian client. The caregiver of the client tells the nurse that the client is having an episode of Bouffée delirante. What symptoms would the nurse expect to find in this client? Select all that apply.

Confusion Hallucinations Extreme aggression Bouffée delirante is a culture-bound syndrome observed in West Africa and Haiti. This condition is characterized by sudden outbursts of aggression. The client is confused and may have auditory and visual hallucinations. Insomnia and abdominal pain are not associated with Bouffée delirante. These symptoms are associated with Hwa-Byung, which is a culture-bound syndrome in Korea.

A client comes in for a therapy session and begins to have a panic attack. The therapist asks the client to relax in the chair and then gently asks the client to imagine the client in a very safe and calm place. This technique, often useful in anxiety disorders, is called what?

Deep breathing Helping the client focus on deep breathing can decrease the hyperarousal involved in panic attacks. It is also an opportunity for the therapist to teach the client self-help and adaptive coping mechanisms for panic attacks.

Which intervention does not meet the standard of care for the client in seclusion?

Documented assessment by the nurse every 3 to 4 hours Documented assessment should take place by the nurse every 1 to 2 hours with close supervision of the client.

Which term is used to describe an emotion expressed through verbal abuse and violation of rules or norms?

Hostility Hostility is an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior. Anger is a strong, uncomfortable, emotional response to a real or perceived provocation. Catharsis includes activities that provide a release of the anger. Physical aggression is behavior in which a person attacks or injures another person or that involves destruction of property.

When staff members physically control the client and move him or her to a seclusion room, what form of restraint is being implemented?

Human Human restraint is when staff members physically control the client and move him or her to a seclusion room. A mechanical restraint is a device, usually ankle or wrist restraints, fastened to a bed frame to curtail the client's physical aggression. Long- and short-term restraint refers to the time frame for the use of the restraint.

The mental health nurse should discuss an emergency plan for leaving abusive situations will when the woman is able to do which of the following? Select all that apply.

Identifies safe places to go Keep emergency money available Makes a spare car key Compile a list of important phone numbers When counseling women who are in abusive situations, the mental health nurse's suggestions that an emergency plan to leave will be facilitated if the woman identifies a safe place to go, keeps emergency money available, makes a spare car key, and compiles a list of important phone numbers. Without the correct options in place for a woman planning to leave an abusive situation, the likelihood that the woman can successfully transition into a new situation is lessened

Which is considered a tricyclic antidepressant (TCA) used in the treatment of clients with panic disorder?

Imipramine The TCAs include imipramine, nortriptyline, and norpramine. Fluoxetine and sertraline are selective serotonin reuptake inhibitors (SSRIs). Lorazepam is a benzodiazepine.

Which are forms of psychological abuse? Select all that apply.

Insulting Humiliating isolating a person from family Psychological abuse includes behaviors such as criticizing, insulting, humiliating, or ridiculing someone in private or in public. It can also involve actions such as destroying another's property, threatening or harming pets, controlling or monitoring spending and activities, or isolating a person from family and friends. Rape and incest are forms of sexual assault.

A nursing instructor is describing the care of a client with acute anxiety to a class of nursing students. The instructor determines that more education is necessary when the students identify which intervention as appropriate?

Providing the client with a comforting touch It is important to establish rapport and trust with the anxious client before using therapeutic touch. Touching an anxious client may actually increase anxiety. Trust can be established by approaching the client in a calm and confident manner; providing a place that is quiet, safe, and private; and encouraging the client to verbalize feelings and concerns.

The nurse's suspicion that a child has been sexually abused is supported by what assessment data? Select all that apply.

The anal area is bruised The child reports "itching down there" The vulva appears edematous The urinalysis reports a bacterial infection The nurse's suspicion that a child has been sexually abused is supported when the assessment data includes a bruised anal area, itching reported by the child, an edematous vulva, and a urinary infection. Ear infections are common among children.

A client comes to the clinic for an evaluation. The nurse assesses the client and suspects that the client is a victim of abuse. Which finding would support the nurse's suspicion? Select all that apply.

The client is vague about the injuries on the body. The client minimizes the severity of the injuries. The client has a history of frequent visits to the emergency department for injuries. Findings that would support a suspicion of abuse include vagueness about any injuries and how they occurred, a delay in seeking treatment for the injuries, minimizing or denying about the severity of the injuries, history of frequent visits to the emergency department for injuries, and feelings of a loss of control or powerlessness.

A nurse is preparing a plan of care for a client with anxiety. Which elements would the nurse likely include? Select all that apply.

Using appropriate coping skills Identifying treatment modalities Involving family for support, if appropriate Providing supportive feedback Appropriate measures to include in the plan of care for a client with anxiety include: introducing appropriate coping skills, identifying alternate treatment modalities, involving family and support persons when appropriate, and providing feedback that is supportive to the client. Restraint is always a last resort.

The nurse is concerned that a client may be experiencing emotional abuse. The nurse observes an interaction between the client and a family member. Which assessment findings related to the actions of the family member toward the client led the nurse to make this clinical determination? Select all that apply.

putting the client down calling the client names making the client feel guilty Behaviors that suggest that someone is experiencing emotional abuse include putting the person down, name-calling, and making the person feel guilty. Making all the decision is a behavior associated with male privilege. Limiting contact with others demonstrates the use of isolation.

The nursing instructor is talking to a class of nursing students about the American's with Disabilities Act, and persons having various disabilities that have the right to education in the least restrictive environment. The nursing instructor asks the students, "what is the reason for the least restrictive environment?" Which example should the student nurse choose?

unique needs Least restrictive environment means the individual cannot be restricted to an institution when he or she can be successfully treated according to the client's needs, and stay in the community. Budget factors, placement options, and availability of space are not factors related to The American's with Disabilities Act.

The nurse states "I know this must be frightening for you" to a client who is angry and has a potential for violence. Which communication technique is the nurse utilizing with this statement?

validation Validation involves a clarification of the client's feelings and when a client is angry, many times it can be due to feeling isolated and anxious. Reflection is redirection of an idea back to the client for classification of emotional overtones. Confrontation involves presenting the client with a different reality of the situation. Acceptance would involve encouraging information in a nonjudgmental and interested manner.

The client asks about a new medication, it's side effects, cost and if the drug is compatable with the other medication the client takes. The nurse answers all questions the client asks without withholding information. The nurse is guided by which ethical principle?

veracity Veracity is the duty to be honest or truthful. The nurse is exercising veracity when fully answering any questions the client is answering without withholding information. Justice, beneficence and fidelity are not the ethical principle described in this question.

Which assessment question should the nurse ask of a client suspected of being ostracized by a school bully?

"Do you feel like a part of a group in school?" Ostracism, ignoring and excluding a target individual, has recently emerged as one of the more common and damaging forms of bullying. The victim experiences threats to belonging, self-esteem, meaningful existence, and sense of control. Ostracism may pose an even greater threat to children's adjustment than bullying. Those who bully are more likely to have poor grades and to use alcohol and tobacco. None of the remaining options are directly associated with the issue of ostracizing.

The nurse manager is reviewing ethical principles at a staff meeting. The manager asks, "What examples of non-maleficence can you provide?" Which response(s) by the staff nurse are mostappropriate? Select all that apply.

"Giving the client an injection for a sexually transmitted infection (STIs)" "Assisting with the client's bone marrow transplant" "Performing chest compressions for a client with no pulse" Non-maleficence is the requirement to do no harm to others either intentionally or unintentionally. Examples include: "Performing chest compressions for a client with no pulse" even though doing chest compressions may facilitate broken ribs; "Assisting with the client's bone marrow transplant" even though doing this may cause pain; "Giving an injection for sexually transmitted infections" even though the injection may cause pain. Teaching the client about medications and encouraging the client to quit smoking or not examples of non-maleficence.

A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence?

"He tells me that he is sorry and that he will never hit me again." During phase 3 of the cycle, the perpetrator becomes kind, contrite, and loving, begging for forgiveness and promising never to inflict abuse again. The actual violence occurs in phase 2. Yelling at the client for not having dinner ready and calling her stupid and incompetent reflect phase 1, or tension building.

A nurse working on a psychiatric unit receives a telephone call from the employer of one of the clients on the unit. The employer asks to be sent a copy of the client's latest laboratory work and psychological testing results so the client's medical records in employee health can be kept up to date. Based on the nurse's knowledge about issues surrounding breach of confidentiality, which response would be the most appropriate?

"I am unable to acknowledge whether or not this client is a client on this unit." A breach of confidentiality is the release of client information without the client's consent in the absence of legal compulsion or authorization to release information. Acknowledging that this client is a client on the unit would be such a breach. Even if the nurse explains that he or she cannot give the information without the client's consent, the explanation lets the employer know that the client is receiving care in a psychiatric hospital.

Which statement, made by a nurse who experienced sexual abuse as as a child, demonstrates being best prepared to work with sexual abuse and trauma survivors?

"I've been supported by health care professionals and now I want to support other survivors." Nurses with a personal history of abuse or trauma must seek professional assistance to deal with these issues before working with survivors of trauma or abuse. Such nurses can be very effective and supportive of other survivors but only after engaging in therapeutic work and accepting and understanding their own trauma. The nurse should not repress the memories of the trauma but rather engage in the work needed to accept the incident. The other options present true statements but none are associated with being prepared to provide the necessary care.

The nurse is complaining about a client that has dementia. The client is mobile and slaps the nurse on the gluteus maximus each time he passes by. The nurse tells the client, "If you don't behave yourself, I am going to throw you out and you won't have anywhere to go." The charge nurse overhears the nurse, and states "Do you realize what your statement could be construed as?" What is the best statement for the nurse to respond?

"It could be construed as assault" Assault involves any action that causes a person to fear being touched in a way that is offensive, insulting, or physically injurious without consent or authority. Battery, negligence, and intentional harm do not involve actions that make a person to fear being touched or physically injured without consent. Battery is the intentional act of causing physical harm to someone. Negligence is when a nurse who is fully capable of caring does not care in the way a reasonably prudent nurse would, and as a result the patient suffers unnecessarily. Unintentional harm is used to refer to injuries that were unplanned.

The mental health nurse is talking to nursing students in an Ethics class and asks, "Which example of an ethical principle is correctly paired with nursing practice?" Which statement by the student would be correct?

"Telling the client that you will come in to help with dressing in 15 minutes, then returning in 15 minutes." Fidelity is faithfulness to obligations and duties and to keep promises, such as telling a client you will do something or return at a certain time. Fidelity is important in establishing trusting relationships. An example of non-maleficence is the statement "The client has the right to refuse treatment." "Treating all client's fairly" is an example of autonomy and "Being thoughtful and honest" is an example of beneficence. All of these statements are not correctly paired with nursing practice.

The nurse is admitting a client to the hospital. The nurse gives the client information about client rights while in the hospital. Which statement by the client indicates that more teaching is needed?

"The doctor can copy my information and send it to my son." Privacy refers to that part of an individual's personal life that is not governed by society's laws and government intrusion. Protecting an individual from intrusion is a responsibility of health care providers. The client is permitted to read the personal medical record. Doctors and nurses cannot give any information out to anyone unless the client agrees, and cannot tell a caller that the client is in the hospital.

A nursing manager is holding a staff meeting and talking about ethical principles. The nurse manager asks, "Which example of an ethical principle is accurately paired with nursing practice?" Which statement by the staff nurse would be correct?

"The nurse treats all clients fairly." Justice is the duty to treat all fairly, distributing the risks and benefits equally. Nursing examples include doing equally for all clients and not giving more attention or supplies to one person over another. "The nurse is always truthful and honest" is an example of non-maleficence, "The nurse takes action to promote clients' health" is an example of autonomy and "The nurse encourages clients to make choices about health care" is an example of fidelity. These statements not paired with the correct nursing practice.

A client comes to the emergency department because the client thinks the client is having a heart attack. Further assessment determines that the client is not having a heart attack but is having a panic attack. When beginning to interview the client, which question would be most appropriate for the nurse to ask?

"What did you experience just before and during the attack?" After it has been determined that the client does not have other medical problems, the nurse should assess for the characteristic symptoms of panic attack, focusing the questions on what the client was experiencing just before and during the attack. Asking the client if the client feels better provides no information for the nurse, and lying down may or may not be effective. Asking the client if the client thinks the client can drive home is a question that can be asked much later in the interview, after the attack subsides and the client is stable. Asking the client about what caused the attack is inappropriate because numerous stimuli, both external and internal, can provoke an attack. Most clients will not be able to identify a specific cause. The focus of care is on the characteristics of the attack.

The nurse is assessing a client of an Eastern culture who is admitted due to the need for anger management. What question should the nurse ask to determine the effect of culture on the client's expression of anger?

"What did you learn about anger when growing up?" While all of these questions are pertinent to assessment of anger reactions in a client, questions related to culture need to center around how clients learned about anger when growing up and how it is displayed. While clients can learn to move past learned behaviors as a child, it is important to understand what these learned behaviors are.

A nurse is preparing to gather a health history of a client. Which questions can elicit disclosure if a client has been abused? Select all that apply.

"When there are arguments at home, have you ever been hurt or afraid?" "It looks like someone has hurt you. Tell me about it." "Some other women I have cared for have described problems like yours. If this is happening to you, can we talk about it." The U.S. Preventive Service Task Force recommends routine screening to detect current or past abuse, and risk of abuse. Most survivors do not report violence to health care workers without being specifically asked about it. Survivors may be reluctant to report abuse due to shame and fear of retaliation. Asking specific abuse screening questions has been shown to increase the detection of abuse substantially. Questions should be open ended and clients may need time to disclose the abuse. Clients need to know the nurse is listening, believes them and is concerned for their safety and well-being. Asking the client about telling the nurse the truth means the nurse does not believe them. By telling the client they are distracted, the nurse is not allowing time for the victim to discuss at their own pace.

A nurse is working in the emergency department. Which situation would lead the nurse to suspect possible abuse of a client? Select all that apply.

A 6-year-old is being seen for the 5th time for a urinary tract infection A baby with contrecoup injuries to the brain A 3-month-old with a fractured femur Re-occurring urinary tract infections signal the possibility of sexual abuse of the child. The nurse must assess for further signs of abuse both with parents present and without. A fracture of the femur in a 3-month-old is uncommon given the infant's age and level of development. Contrecoup injuries of the brain in a baby should generate suspicion that the baby has been shaken. A 15-month-old with an allergic reaction to a peanut ingestion and a 3-year-old with a deep finger laceration should not signal abuse to the assessor. The problems are commonly seen in the pediatric emergency room.

A nurse suggests that the client explores new ideas about a particular problem and considers other possibilities to reflect:

A cognitive intervention. Cognitive interventions are usually those that provide new ideas, opinions, information, or education about a particular problem. The nurse offers a cognitive intervention with the goal of inviting the client to consider other possibilities.

What is provided in the Code of Ethics for Nurses of the American Nurses Association (ANA)?

A guideline for nurses regarding ethical conduct The ANA's Code of Ethics for Nurses guides ethical decision-making.

Which describes a strong emotional response to a real or perceived provocation?

Anger Anger is a strong, uncomfortable, emotional response to a real or perceived provocation. Physical aggression is behavior in which a person attacks or injures another person or that involves destruction of property. Catharsis includes activities that provide a release of the anger. Hostility is an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior.

A hospitalized client states that the client is having difficulty resting. Which intervention would help promote rest?

Assisting the client with deep-breathing exercises Deep-breathing exercises are beneficial to promoting rest as they help the client to relax. The client's door should be closed to reduce noise and distractions. Tea contains caffeine, which acts as a stimulant. While sedatives may be used occasionally for assistance with rest, regular use isn't advised because dependence may develop.

A client is being seen in the mental health clinic because of relapse. The client has been nonadherent with the medication regimen. The nurse reinforces the advantages of taking medications. The nurse is using which ethical principle?

Beneficence According to the principle of beneficence, the health care provider uses knowledge of science and incorporates the art of caring to develop an environment in which people achieve their maximal health care potential. According to the principle of autonomy, each person has the fundamental right of self-determination. Justice is the duty to be treated fairly. Veracity is the duty to tell the truth.

A new nursing student is studying ethics in nursing and informs a client who wants to stop medication about its benefits and how the client will continue to feel better only if use of the drug continues. Which concept is the nursing student using?

Beneficence Beneficence is the principle of using the knowledge of science and incorporating the art of caring to develop an environment in which individuals achieve their maximal health care potential. It is "doing good."

A client with persistent depression is considering electroconvulsive therapy (ECT). The nurse has seen ECT be effective in other cases. When the client expresses fear and doubt about undergoing ECT, the nurse tries to talk the client into it, because the nurse truly believes it will help the client. Which two ethical concepts are in conflict?

Beneficence and autonomy Beneficence and autonomy are in conflict. Beneficence is practicing with the intent to do good; however, professionals define how to do good, which may override the wishes and self-determination of the client. Autonomy is the client's right to make decisions for himself or herself. Justice refers to fairness; that is, treating all people fairly and equally without regard for social and economic status, race, sex, marital status, religion, ethnicity and cultural beliefs. Fidelity is the nurse's faithfulness to duties, obligations, and promises.

A female client states that she has been receiving numerous text and phone messages from a co-worker. Which type of harrassment should be documented in the nurse's notes?

Cyberstalking Stalking is a pattern of repeated unwanted contact, attention, and harassment that often increases in frequency. Cyberstalking is the use of the Internet, e-mail, or other telecommunications technology to harass or stalk another person. The nurse should document the conversation in the nurse's notes.

What assessment data, related to a 77 year old client, would be considered the highest risk for possible elder abuse?

Diagnosed with mild dementia While the risk of elder abuse exists in all the options provided, such abuse is more likely when the elder client has chronic mental and/or physical health problems that limit there ability to express their concerns and/or describe their current living conditions.

A mental health nurse is interviewing a child for suspected abuse. The parent states that the child is having disciplinary problems at school and stutters when approached. From the listed behavioral indicators, the nurse would suspect which type of abuse?

Emotional A behavioral profile of an emotionally abused child includes stuttering, enuresis, overeating, disciplinary problems, and failure to thrive. The scenario does not refer to physical, financial, or sexual abuse.

Which staff behaviors are most likely to trigger clients who are predisposed to aggressive or violent behavior?

Engaging in disputes over medication, supplies, or rules on the unit Nurses who show respect and empathy are more likely to defuse a client's anger than are nurses who are authoritarian. Examples of authoritarian behavior include preventing clients from leaving the ward, engaging in disputes with them over medication, generally enforcing rules or denying requests, physically restraining clients, taking something from them, ignoring them, or requesting clients to do or not to do something.

A nurse is gathering information about a health history of a person who has experienced violence. Which are important caring behaviors a nurse should implement during the interview? Select all that apply.

Establish trustworthiness. Maintain a nonjudgmental attitude. Secure open communication. Establishing a trusting nurse-client relationship is one of the most important steps in caring for any person experiencing violence. Survivors are unlikely to disclose sensitive information unless they perceive the nurse to be trustworthy and nonjudgmental. Important considerations in establishing open communication are ensuring confidentiality and providing a quiet, private place to which to interact. The nurse must continually monitor personal feelings toward the perpetrator and survivor, especially in cases of child abuse or in situations where the person decides to remain in an abusive relationship. Seeking value clarification by the nurse may prevent negative feelings from influencing the nurse-client relationship that could lead to a nontherapeutic interaction and perhaps re-traumatize the survivor. The nurse should not ask about religious background or disclose personal feelings about the victim.

Nursing interventions for physical stress related illness should include what?

Establishing daily routines of meals and sleeping Individuals experiencing or at risk for untoward stress responses may benefit from a number of biologic interventions. The importance of (re-)establishing regular routines for activities of daily living (e.g., eating, sleeping, self-care, and leisure time) cannot be overstated. As well as ensuring adequate nutrition, sleep and rest, and hygiene, a routine may help to structure an individual's time and give them a sense of personal control or mastery.

A client's plan of care includes revoking privileges for inappropriate behavior, based on a contract between the client and the nurse who wrote the plan. Another nurse decides to ignore this because the client promises that the client will adhere to the contract in the future. The second nurse's behavior may have violated which ethical principle?

Fidelity Fidelity is the nurse's faithfulness to duties, obligations, and promises. Autonomy is the client's right to make decisions for himself or herself. Veracity is a systematic behavior of honesty and truthfulness in speech. Beneficence is the principle of doing good, not harm.

The nurse is assessing a client who is aggressive. Which safety measures must the nurse ensure are in place prior to continuing the assessment? Select all that apply.

Give the client plenty of space. Sit in an open area Request the presence of additional staff. While assessing an aggressive client, the nurse should give the client plenty of space, sit in an open area, and request the presence of another staff person. The nurse should not restrain the client by him- or herself, but rather get the client restrained by trained personnel. Encouraging the client to talk about the situation in which he or she has been aggressive should be done in the recovery phase of the anger cycle.

Nurses working with rape trauma victims need to be aware of their own attitudes about rape and sexual assault. Which rationale best explains why?

Giving back the survivor as much control as possible is important. Knowing how to recognize when personal feelings are likely to interfere with optimal care is part of the nurse's professional responsibility. Giving back the survivor as much control possible is important by allowing the client to make decisions about who to call, what to do next, and what the client would like done in relation to the crime. The nurse's role in helping the survivor regain control is an essential part of recovery.

The nurse is preparing a teaching plan for a client who experiences intimate partner violence. Which topics should the nurse include? Select all that apply.

HIV testing sleep hygiene access to shelters nutritional support When caring for the client who has been abused, the nurse teaching plan should include information about HIV testing, sleep hygiene, access to shelters, and adequate nutrition. Employment counseling is not identified as a topic when teaching the client who has been abused.

The nurse finds that a client with a history of aggressive behavior is restless, is pacing up and down in the hallway, and has clenched fists. The client also talks in a loud voice. Which intervention would be most appropriate at this point?

Immediately approach the client to engage in communication The client's behavior and history of aggression indicates the nurse should explore the underlying cause of the escalating behavior in order to address the client's needs prior to moving into the escalation stage of aggression.

A nurse manager is working with the nursing staff of a busy community-based walk-in clinic that provides care to a large number of survivors of domestic violence. When helping the staff provide care, which information would be most important for the nurse manager to convey to the staff?

Importance of measuring the clients' progress in small steps Nurses must become accustomed to measuring gains in small steps when working with survivors. Making any changes in significant relationships has serious consequences and can be done only when the adult survivor is ready. It is easy to become angry or discouraged with survivors, so it is important not to communicate such feelings. Discussing such feelings with other staff provides a way of dealing with them appropriately. In such discussions with supervisors or other staff, it is a must to protect the patient's confidentiality by discussing feelings around issues, not particular patients.

Which personality trait is associated with aggressive behavior?

Impulsivity Irritability, resentment, and impulsivity have been linked with conflict, aggression, and the potential for medical conditions such as essential hypertension, cardiovascular disease, and atherosclerotic heart disease.

A nurse is working with a client who is anticipating the possibility of leaving an abusive relationship. In helping the client make the decision to leave or to stay in the abusive situation, which would be most important for the nurse to do?

Inform the client that if leaving the abusive situation, there is a possibility the partner will attempt to fatally injure the client. Survivors must understand the cycle of violence and the danger of homicide that increases as violence escalates or when the survivor attempts to leave the relationship. Although survivors also need information about resources (e.g., shelters for battered women), legal services, government benefits, and support networks, the nurse first needs to discuss the possibility of the perpetrator's reaction and the possibility of extreme violence leading to death.

A group of students is reviewing information about the etiology of generalized anxiety disorder (GAD). The students demonstrate understanding of this information when they identify which as representing the bases for this disorder?

Intense worry and stress about work or simple family life Adults with GAD often worry about matters such as their job, household finances, health of family members, or simple matters (e.g., household chores or being late for appointments). The intensity of the worry fluctuates, and stress tends to intensify the worry and anxiety symptoms. Cognitive behavioral theory regarding the etiology of GAD proposes that the disorder results from inaccurate assessment of perceived environmental dangers. Although there are no specific sociocultural theories related to the development of GAD, a high-stress lifestyle and multiple stressful life events may be contributors. Kindling results from overstimulation or repeated stimulation of nerve cells by environmental stressors.

Which ethical principle is in jeopardy when segments of the mentally ill population do not have access to care?

Justice Justice becomes an issue in mental health when a segment of a population does not have access to health care. Fidelity is faithfulness to obligations and duties. Autonomy is the fundamental right of self-determination. Paternalism is the belief that knowledge and education authorize professionals to make decisions for the good of the client.

A client diagnosed with panic disorder has been receiving medication therapy, which is being discontinued. A nurse would be alert for possible withdrawal symptoms if the client was receiving what?

Lorazepam Discontinuation of benzodiazepines, such as lorazepam, places the client at risk for withdrawal symptoms. Withdrawal is not associated with duloxetine, a serotonin-norepinephrine reuptake inhibitor, or escitalopram or fluvoxamine, selective serotonin reuptake inhibitors.

A client has been in a physically abusive relationship for more than a decade. Which statement best demonstrates that the client understands of how fear can influence a reluctance to leave such a relationship?

My partner would hunt me down and kill me for sure." Leaving an abusive relationship is a process that can be quite complex. Fear is one of the most important factors in deciding whether to leave or to stay in a violent relationship. Victims recognize the valid concern that leaving may not stop the violence. If victims attempt to leave or actually do leave the relationship, perpetrators often escalate their violence, stalk their partners, and may even kill them, which makes leaving the time of greatest risk in intimate partner violence. While all the options present reasons to stay, the most compelling is fear of future violence and possible death.

When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as what?

Nonmaleficence Nonmaleficence is the principle of creating no harm. It refers to preventing or minimizing harm to an individual. The other options do not represent the situation presented in the question.

A nurse is working on developing a safety plan with a client who is a survivor of violence. Which would the nurse address first?

Recognizing the signs of danger One of the most important teaching goals is to help survivors develop a safety plan. The first step in developing such a plan is helping the survivor recognize the signs of danger. Changes in tone of voice, use of alcohol and other drugs, and increased criticism may indicate that the perpetrator is losing control. Detecting early warning signs helps survivors to escape before battering begins. The next step is to devise an escape route. This involves mapping the house and identifying where the battering usually occurs and what exits are available. The survivor needs to have a bag packed and hidden, but readily accessible, containing what is needed to get away. If children are involved, the adult survivor should make arrangements to get them out safely. That might include arranging a signal to indicate when it is safe for them to leave the house and to meet at a prearranged place. A safety plan for a child or dependent older adult might include safe places to hide and important telephone numbers, including 911, police and fire departments, and other family members and friends.

Relaxation techniques help clients with anxiety disorders because they can promote what?

Reduction of autonomic arousal Regularly inducing the relaxation response reduces the general level of autonomic arousal in anxious clients. It lowers blood pressure, heart rate, metabolic rate, and oxygen demands. This physiologic effect may result from effects on the production of cortisol, a hormone the body releases in response to stress. Cortisol is helpful during the fight-or-flight response, but its prolonged presence in chronically anxious or stressed clients can inhibit the immune system and have other deleterious effects on the body.

The nurse is demonstrating de-escalation techniques on an aggressive client in a forensic setting. Which is the best explanation of this technique?

Resolution of anger in nonviolent ways The primary goal of de-escalation is to resolve angry or violent conflicts in nonviolent ways. Stopping dangerous behavior by pointing out unacceptable behavior is behavior correction. Role modeling is one part of behavior correction. Early recognition involves increase client self-awareness of early signs of their aggressive behavior and reinforces self-management skills that decrease the likelihood of using aggression in future situations.

A client has been admitted to the detoxification unit after binge drinking. Even though the client is not currently intoxicated, the client is combative and exhibits altered thought processes. Which nursing diagnosis would be the priority?

Risk for other-directed violence related to alcohol withdrawal The priority nursing diagnosis is risk for other-directed violence related to alcohol withdrawal. The most common nursing diagnoses for clients experiencing intense anger and aggression are risk for self-directed violence and risk for other-directed violence. Although the other answers are possible nursing diagnoses, there is no evidence to support a risk for injury, self mutilation, or delayed development.

Which type of rapist derives erotic gratification from the victim's suffering?

Sadistic rapist Sadistic rapists derive erotic gratification from the victim's suffering. Power rapists often attack people their own age and use intimidation and minimal physical force to control their victims. Their assaults are premeditated. Anger rapists use extreme force and restraint that results in physical injury to the victim. There is not a type of rapist called premeditated.

A client is diagnosed with intermittent explosive disorder. The nurse understands that this disorder is associated with which neurotransmitter?

Serotonin Intermittent explosive disorder involves inadequate production or functioning of serotonin. Other neurotransmitters such as dopamine, norepinephrine, or GABA are not involved.

A client tells the nurse that the client has strong urges to damage property as a result of feelings of hostility and anger. Which is an appropriate nursing action?

Take the client to the gym for exercise. For a client who expresses hostile and aggressive feelings, the nurse can help the client vent the anger and hostility in a nondestructive way by taking the client to the gym to perform physical exercise. As the client is not severely agitated, the nurse should not put the client in seclusion. Restraints are not required unless the client is a potential threat to safety of self and others. Talking to the client in a firm voice may increase the agitation of the client.

A client has recovered from an episode of aggressive and hostile behavior. Which behaviors in the client indicate that the client is in the post-crisis stage of the aggression cycle? Select all that apply.

The client apologizes for the hostile behavior. The client cries and is remorseful for the event. The client remains withdrawn from others. There are five phases of an aggression cycle. These include triggering, escalation, crisis, recovery, and post-crisis. In the post-crisis phase, the client attempts reconciliation with others and returns to a normal level of functioning. The client may realize that the aggressive behavior was wrong and may apologize for it. The client may cry and feel remorse for the aggression episode. Due to the guilt related to the aggression episode, the client remains withdrawn from others. The client talking in a loud voice, exhibiting irritable behavior, and pacing restlessly indicates that the client is in the triggering phase of the aggression cycle.

A psychiatric treatment team is planning care for a client who was involuntarily admitted for treatment of depression and suicide ideation. When planning care, of what legal parameters of care must the nurse be aware?

The client can refuse medication. Competent clients have the right to refuse medication. Even thought the client is an involuntary admission, the client is competent and able to be involved in treatment planning. Because the client was admitted involuntarily, the client is not able to obtain release. The client who is legally declared incompetent is given a court appointed guardian or representative who is responsible for giving consent. A client is considered competent unless the court has declared that the client is incompetent. The client who is incompetent is not able to give or refuse consent for treatment.

A client reports the client has been experiencing increased stress at work. The client has been managing the stress by drinking 2-3 glasses of wine per evening. Despite the nurse recommending that drinking alcohol is not an effective way to manage the stress, the client reports it is unlikely that the client will be able to stop. Which statement explains why this will be difficult for the client?

The client has no adaptive coping mechanisms. Clients learn to reduce the anxiety they feel in either functional or dysfunctional ways. The nurse first explores with the client what techniques the client has used in the past and helps the client identify and enhance those strategies that are most beneficial. The nurse and client identify maladaptive coping strategies, such as social withdrawal or alcohol use, and replace them with adaptive strategies that suit the client's personal, cultural, and spiritual values. The nurse should not ask the client to give up coping mechanisms, even maladaptive ones, without offering other adaptive mechanisms.

The nurse is aware that fewer than half of rapes and sexual assaults are reported. Which are some of the reasons people do not report being sexually assaulted? Select all that apply.

The client is embarrassed of the assault. They have a fear of being blamed for the incident. The perpetrator may use coercion or threats to control the victim. Fewer than half of rapes and sexual assaults are reported, generally because of shame, embarrassment, concern about not being believed or fear of being blamed for the assault. Knowing the attacker may also be a factor that inhibits reporting. The majority of sexual violence is perpetrated by intimate partner or acquaintances and does nto involve weapons or severe physical violence. The perpetrator may use coercion, threats, or substances to control the victim. The nurse needs to understand these reasons to develop a therapeutic relationship to assist in the care of the client victim.

A nurse is reviewing a journal article about malpractice and the elements required to prove negligence. The nurse demonstrates a need for additional review when the nurse identifies which element as being necessary?

The client must be injured physically as a result of the nurse's action. As a result of the failure to meet the standard of care, the plaintiff consumer was injured, and the nurse's action was the proximate cause of the injury. The act must have resulted in some kind of injury to the client. However, the injury does not have to be physical; it can be emotional injury as well.

A nurse has been a victim of assault by a client. Which physiologic response would the nurse exhibit to indicate that there was a more long-term consequence for this event?

The nurse discusses the difficulty of being able to sleep at night. The nurse who is experiencing a physiological response would potentially have difficulty sleeping, or report headaches or stomach aches. The client who expresses fear and anxiety is having an affective response to the experience. The nurse seeking another job is having a cognitive response to the violence. The nurse eating alone is demonstrating a feeling of isolation, which is a behavioral response.

Which situations depict a nurse employing the principles of fidelity while providing care? Select all that apply.

The nurse tells the client, "I will return to give you pain medication in 1 hour." The nurse returns in 1 hour. Fidelity is faithfulness to obligations and duties, such as telling a client you will do something and returning to complete the task. The client asking questions about surgery and the nurse answering the questions completely, the nurse giving information the client needs to make a decision and the nurse telling the complete truth are not examples of fidelity.

A nurse is considering using restraint and seclusion for a client who is acting out. Which is the primary guideline for the use of restraint and seclusion?

Use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent. Because of the risks of restraint and seclusion, a primary guideline is that use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent. Furthermore, restraint and seclusion should be applied only when other less restrictive methods to ensure client safety have failed. Nonphysical interventions are the first choice.

An adolescent client has refused to wash or change clothes for several days. The client's hair is greasy, the client's clothes are stained, and the client has a strong malodor. Three male staff members approach the client to escort the client to the shower. The client resists and becomes combative with staff members. The client is placed in seclusion and is told the client will be released when the client is calm and willing to shower. Which is an accurate statement of the client's rights in this situation?

Violated, primarily because of the inappropriate use of restraints Clients have the right to treatment in the least restrictive environment. No staff can confine a person with mental illness who is not a threat to self or others. Nurses must assess a client's condition and status constantly so that health care professionals can initiate more or less restrictive treatment alternatives based on the client's evolving needs.

The client is brought to the hospital in a coma. The nurse understands that when a person is incapacitated, the document used to dictate the patient's written instructions for health care is called:

advance directive Advance care directives are written instructions for health care when individuals are incapacitated. Informed consent, durable power of attorney, and patient rights are not instructions for health care when individuals are incapacitated. A durable power of attorney means that the advance care directives stays in effect if you become incapacitated and unable to handle matters on your own. Informed consent is the permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits. Patient rights are those basic rule of conduct between patients and medical caregivers as well as the institutions and people that support them.

A young adult client female is assessed after being raped. The client reports being tied up and beaten while the perpetrator forced sexual intercourse. She recalls the perpetrator saying, "I will make you pay." What most accurately describes this category of rapist?

anger retaliation In this case, the most accurate description of this rapist is anger retaliation. In this category, the perpetrator wants to punish the victim and often causes substantial injury. The power assertive rapist desires to dominate and control the victim and may repeat with the same victim. The power reassurance rapist commits rape when the opportunity presents itself, such as when another crime is being committed. An anger excitement rapist acts out fantasies and can be strategic in carrying out the crime, for example, carries a rape kit.

A client with depression tells the nurse, "I want to stop taking my antidepressant medication because I don't like taking medications." The nurse discusses the benefits of adhering to the medication plan and strongly urges the client to use the medication. The nurse interprets the client's statement as reflecting which ethical principle?

autonomy Autonomy reflects the fundamental right of all persons for self-determination, to make independently make choices. Autonomy is reflected by the client's statement to stop taking the medication. The nurse's urging the client to continue to use the medication because of the medication's benefits reflects the principle of beneficence, that is, the nurse is using scientific knowledge and incorporating that knowledge to promote the client's maximum health potential. In this case, the medication would help to control the client's depressive symptoms. Justice reflects the duty to treat all fairly; paternalism is the belief that knowledge and education authorize professionals to make decisions for the good of the client.

The client has not been on speaking terms with the client's parents for several years. The parents have expressed a desire to reunite with the client. At first, the client agreed to a family meeting, and then decided not to meet with the parents. The nurse has encouraged the client to attend the family meeting knowing that the family's support would be valuable. What ethical principles are in conflict in this situation?

autonomy and beneficence According to the principle of autonomy, each person has the fundamental right of self-determination. According to the principle of beneficence, the health care provider uses knowledge of science and incorporates the art of caring to develop an environment in which individuals achieve their maximal health care potential. The client has the right to decide whether to go to a family meeting or not, and the nurse urges the client to go to the meeting because the nurse knows that the family will be a great support to the client. The ethical principles that are not in conflict in this situation are justice and beneficence, non-maleficence and autonomy, and veracity and fidelity.

A physician who fails to obtain informed consent before performing a procedure is subject to liability for:

medical battery. Medical battery, intentional and unauthorized harmful or offensive contact, occurs when a client is treated without informed consent. Assault is the threat of unlawful force to inflict bodily injury upon another. False imprisonment is detention or imprisonment contrary to provision of the law. Battery is intentional and unpermitted contact with another.