Mental Health Exam 2 Remediation Prep U
A client who has a recent diagnosis of bipolar I disorder is scheduled to begin therapy with lithium. Which instruction should the nurse provide to this client? "Avoid exercise at the hottest times of the day." "Try to limit your fluid intake to no more than four to six glasses per day." "Try to adapt to a low-salt diet as soon as possible." "If you don't feel substantially different in a few days, increase your dose by 50%."
"Avoid exercise at the hottest times of the day." Explanation: Heavy perspiration increases the possibility of adverse effects during lithium therapy. A high-fluid diet with normal levels of salt is indicated, and doses should not be independently adjusted.
On observing a client diagnosed with posttraumatic stress disorder (PTSD), the nurse suspects that the client is dissociating. What questions should the nurse ask the client to confirm the suspicion? Select all that apply. "Can you see me?" "Are you able to hear me?" "Have you been taking drugs recently?" "How many hours do you sleep a day?" "Are you woken up by nightmares?"
"Can you see me?" "Are you able to hear me?" Explanation: Since the nurse suspects that the client is dissociating, the nurse should ask questions regarding how aware the client is of his or her reality. Questions that state whether the client can see or hear reflect the client's ability to be associated with reality. Because the nurse suspects that the client is unaware of reality, questions regarding drug history, hours of sleep, and sleep disturbances should not be asked. The client may not be in an appropriate state to answer these questions.
A client is diagnosed with posttraumatic stress disorder (PTSD). What questions should the nurse ask the client to elicit information about the symptoms? Select all that apply. "Do you have recurrent and intrusive thoughts of the trauma?" "Do you feel detached from others?" "Do you get irritated by trivial issues?" "Do you have a past history of any surgery?" "Did you have trouble with social relationships as a child?"
"Do you have recurrent and intrusive thoughts of the trauma?" "Do you feel detached from others?" "Do you get irritated by trivial issues?" Explanation: The three major symptoms of PTSD are reexperiencing of the trauma, emotional numbing, and hyperarousal. Therefore, the nurse should ask relevant questions to determine related behavior. Asking whether the client has recurrent and intrusive thoughts about the traumatic event helps to determine if the client is reexperiencing trauma. Feelings of being detached from others suggests emotional numbing. Getting irritated by trivial issues suggests hyperarousal. While a past history of surgery is important information, it does not help in establishing symptoms of PTSD. Exploring the client's childhood social relationships indicates the nurse is assessing for disorders resulting from childhood trauma such as reactive attachment disorder or disinhibited social engagement disorder, two diagnoses which differ from PTSD.
A nursing instructor is teaching about depressive disorders and identifies a need for further instruction when a student states what? "Dysthymic disorder is milder than major depression." "Dysthymic disorder is less chronic than major depression." "It is also known as persistent depressive disorder." "Major depression may be preceded by dysthymic disorder."
"Dysthymic disorder is less chronic than major depression." Explanation: Persistent depressive disorder (dysthymic disorder) is a long duration mood disorder that has a lower intensity of depressive symptomatology. It may precede major depression.
A psychiatric nurse's colleague has expressed a reluctance to assess a client's risk for suicide, stating, "The last thing I want to do is to plant the thought in the client's head and bring on a suicide attempt." What is the nurse's best response? "Evidence shows that talking about suicide with clients doesn't cause suicide attempts." "We have an ethical responsibility to assess our clients for suicide risk, even if there are risks associated with doing so." "If a client is determined to make an attempt at suicide, there's nothing you or I can do to alter that." "Could it be that you're experiencing countertransference around your own fears of suicide?"
"Evidence shows that talking about suicide with clients doesn't cause suicide attempts." Explanation: It is untrue that asking clients about suicide provokes suicide attempts. However, it not true that nurses are powerless to influence clients' thoughts and actions around suicide in general. The colleague's reluctance is likely motivated by incorrect knowledge, not countertransference.
A client with paranoid personality disorder is admitted to a psychiatric facility. Which statement by the nurse would best establish rapport and encourage the client to confide in the nurse? "I get upset once in a while, too." "I know how you feel. I'd feel the same way in your situation." "It bothers me when I think people are talking about me." "It's normal not to trust anyone."
"I get upset once in a while, too." Explanation: Sharing a benign, nonthreatening, personal fact or feeling helps the nurse establish rapport and encourages the client to confide in the nurse. The nurse cannot know how the client feels. Telling the client otherwise would justify the suspicions of a paranoid client; furthermore, the client relies on the nurse to interpret reality.
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 can stop my medication when I start to feel better." "I should go to sleep at night when I feel tired." "I need to eat properly so that I can control my weight." "I can vary my routines from day to day without problems."
"I need to eat properly so that I can control my weight." Explanation: 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 client with bipolar disorder, having experienced a depressive episode, is prescribed lamotrigine. After educating the client on this medication, the nurse determines that the education was successful when the client states what? "I need to notify my physician if I develop a skin rash." "I need to have my blood tested about once a month." "I have to watch how much salt I use every day." "This drug can affect my liver function."
"I need to notify my physician if I develop a skin rash." Explanation: Lamotrigine has a boxed warning for skin rash, which should be reported immediately if it develops. In most cases, the rash is benign, but it is not possible to predict whether the rash is benign or serious (Stevens-Johnson syndrome). Blood testing is needed for other mood stabilizers such as lithium, divalproex, and carbamazepine. Salt is a concern with lithium therapy. Liver function can be affected by carbamazepine.
A client asks the nurse whether the client needs to alter any of the client's activities because the client is taking lithium carbonate. Which response would be most appropriate? "Increase your salt intake if an activity causes you to perspire heavily." "Wear sunscreen when you are going to be outdoors in the summer." "Drink less fluid than usual now that you are taking this drug." "No changes are necessary for strenuous activities you do outdoors."
"Increase your salt intake if an activity causes you to perspire heavily." Explanation: If body fluid decreases significantly because of a hot climate, strenuous exercise, vomiting, diarrhea, or a drastic reduction in fluid intake, then lithium levels can rise sharply, causing an increase in side effects with progression to lethal lithium toxicity. Clients should increase salt intake during periods of perspiration, increased exercise, and dehydration.
A client with schizophrenia tells the nurse, "I'm being watched constantly by the Federal Bureau of Investigation because of my job." Which response by the nurse would be most appropriate? "Tell me more about how you are being watched." "It must be frightening to feel like you're always being watched." "You're not being watched; it's all in your mind." "You are experiencing a delusion because of your illness."
"It must be frightening to feel like you're always being watched." Explanation: When interacting with a client who is experiencing delusions, the nurse must remember that these experiences are real for the client. Based on the client's statement, the nurse should focus on the feelings that are generated by the delusion, such as acknowledging how frightening it must be to feel constantly watched. The nurse should not focus on the delusion itself (such as by asking the client to tell the nurse more about being watched). Telling the client that the client is not being watched, that it is all in the client's mind, or that the client is experiencing a delusion would be inappropriate because these statements tell the person that his or her experiences are not real.
A client with schizoaffective disorder is prescribed clozapine to treat symptoms. Which instructions would the nurse provide? "Keep a record of how often and how long you experience the side effect of dry mouth." "Monitor your urinary output and notify your doctor if your urine changes color." "Keep an eye on your weight, and if you gain weight rapidly, notify your doctor." "If you experience any drowsiness, discontinue taking this medication."
"Keep an eye on your weight, and if you gain weight rapidly, notify your doctor." Explanation: 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 providing care for a client diagnosed with obsessive-compulsive disorder (OCD), indicates a need for additional education regarding the client's ritualistic hand washing? "Let me help you find something less time consuming to do to manage your anxiety." "Let's talk about how this ritualistic behavior makes you feel." "I believe you when you say you just can't stop washing your hands." "Let's talk about how you plan to manage your anxiety in the years to come."
"Let me help you find something less time consuming to do to manage your anxiety." Explanation: People with OCD are usually aware that their ritualistic behavior appear senseless or even bizarre to others. Given that, family and friends may believe that the person "should just stop" the ritualistic behavior. "Just find something else to do" or other unsolicited advice only adds to the guilt and shame that people with OCD experience. It is important for the nurse (and other health professionals) to avoid taking that same point of view. Most times, people with OCD appear "perfectly normal" and therefore capable of controlling their own behavior. The nurse must remember that overwhelming fear and anxiety interfere with the person's ability to monitor or control their own actions. In addition, OCD is often chronic in nature, with symptoms that wax and wane over time. Just because the client has some success in managing thoughts and rituals doesn't mean they will never need professional help in the future.
A client in the psychiatric unit of the hospital has a diagnosis of schizophrenia. The client has approached the nurse in the hallway of the hospital and is elaborating in great detail about the client's delusions of persecution involving secret societies, the Vatican, and the mafia. How should the nurse respond to the client's expression of these delusions? "Do you think that your delusions might be causing you to think this way?" "That sounds very stressful for you. Would you like to join me and the others in the lounge?" "What can I do to help you get away from these people who want to get you?" "Remember that none of this is real and that no one at all is trying to harm you."
"That sounds very stressful for you. Would you like to join me and the others in the lounge?" Explanation: The most therapeutic response to a client's delusions is to empathically acknowledge the stress that these delusions may cause and to redirect the conversation in a respectful way. Accusing the person of delusional thinking, acknowledging the reality of the delusions, and trying to convince the person that the delusions are not real are interventions that may provoke rather than relieve symptoms.
The spouse of a client diagnosed with complex somatic symptom disorder asks the nurse, "What causes this condition?" Which response by the nurse would be most accurate? "There is definitely an underlying genetic link for this disorder." "Your spouse is experiencing chronic stress that causes hypoarousal." "The symptoms reflect an emotion that your spouse cannot verbalize." "The symptoms reflect an internal preoccupation with events."
"The symptoms reflect an emotion that your spouse cannot verbalize." Explanation: Complex somatic symptom disorder has been explained as a form of social or emotional communication, meaning that the body symptoms express an emotion that cannot be verbalized by the individual. Although there is some evidence to support a genetic component, the exact transmission mechanism is unclear. In individuals with this disorder, chronic activation of the hypothalamic-pituitary-adrenal axis indicates a hyperarousal condition from chronic stress. Additionally, the personality trait alexithymia is associated with somatic symptoms. These individuals have difficulty identifying and expressing their emotions, have a preoccupation with external events, and are described as concrete thinkers.
A client comes to the emergency department reporting a severe pounding headache in the temples and a stiff neck. The client is flushed and diaphoretic, and the client's pulse is racing. The client states that the client is being treated for depression with an MAOI. Which question by the nurse would be most important to ask at this time? "When did you last have blood drawn to check your drug level?" "What have you had to eat or drink today?" "Are you having any chest pain?" "Do you use any herbal remedies?"
"What have you had to eat or drink today?" Explanation: The client is exhibiting signs of a hypertensive crisis, which can occur when a client is receiving MAOI therapy and ingests food or other substances that contain tyramine. Thus, the nurse should ask the client what the client has had to eat or drink. Drug levels are used to monitor tricyclic antidepressants. Asking about chest pain would be appropriate after obtaining information related to what the client has ingested. Herbal remedies can interact with medications, but this information would be obtained after determining whether the client has ingested foods and fluids containing tyramine.
When a woman in the last weeks of her pregnancy expresses concern over experiencing postpartum depression (PPD) after the birth of her baby, which response by the nurse indicates the use of therapeutic communication? "While PPD occurs in only 1 out of 10 new moms, if you experience feelings of sadness or anxiety, or if you have problems sleeping or eating, call your health care provider for help with this treatable disorder." "What makes you feel that you'll get depressed after your baby's birth?" "Only about 1 out of 100 women experience the really severe symptoms but if you eat right, get enough sleep, and accept help from family and friends you aren't likely to have any problems." "The greatest risk of developing the depression is greatest around the baby's 3-month birthday."
"What makes you feel that you'll get depressed after your baby's birth?" Explanation: Although it is important to provide information and probability statistics about PPD to a pregnant client who is concerned about developing this mental health condition, the nurse best demonstrates therapeutic communication by using exploring to learn more about the client's concerns. A female client who has experienced PPD in the past is more likely to experience this with proceeding births. The statistics offered are not accurate, 1 out of 10 women are likely to experience PPD. The greatest risk of developing PPD is about 4 weeks after the birth of the baby.
A client is seen in the clinic with clinical manifestations of an inability to sit still and a rigid posture. As the nurse performs the assessment, which of these side effects would be correctly identified? Tardive dyskinesia Neuroleptic malignant syndrome Dystonia Akathisia
Akathisia Explanation: Akathisia is reported by the client as an intense need to move about. The client appears restless or anxious and agitated, often with a rigid posture or gain and a lack of spontaneous gestures. The symptoms of tardive dyskinesia include involuntary movements of the tongue, facial and neck muscles, upper and lower extremities, and truncal musculature. Tongue thrusting and protruding, lip smacking, blinking, grimacing, and other excessive unnecessary facial movements are characteristic. Neuroleptic malignant syndrome is a potentially fatal reaction manifested by rigidity, high fever, and autonomic instability. Acute dystonia includes acute muscular rigidity and cramping, a stiff or thick tongue with difficulty swallowing, and, in severe cases, laryngospasm and respiratory difficulties.
Which intervention by the nurse will increase the client's sense of security? Allowing the client to perform the rituals Distracting the client from rituals with other activities Encouraging the client to talk about the purpose of the rituals Stopping the client from performing the rituals
Allowing the client to perform the rituals Explanation: The client performs rituals to decrease anxiety and will feel most secure when performing the rituals. The other choices would not promote a sense of security of the client.Clients cannot often be distracted from their rituals and experience anxiety and insecurity if their rituals are "blocked." The client cannot normally articulate specific purpose of the rituals. Stopping the client from performing them would inhibit the therapeutic relationship and cause great anxiety for the client.
A client is diagnosed with paranoid personality disorder. Which would the nurse expect to assess? Select all that apply. Anger as a emotional response Distancing self from others Outwardly passive Tendency to be rigid and controlling Warm and full of humor
Anger as a emotional response Distancing self from others Tendency to be rigid and controlling Explanation: People with paranoid personality disorder are unforgiving and hold grudges; their typical emotional responses are anger and hostility. They distance themselves from others and are outwardly argumentative and abrasive; internally, they feel powerlessness, fearful, and vulnerable. Other hallmark features of paranoid personality disorder are persistent ideas of self-importance and the tendency to be rigid and controlled. Blind to their own unattractive behaviors and characteristics, they often attribute these traits to others. Their outward demeanor often seems cold, sullen, and humorless.
An inappropriately dressed client has not slept for 3 days and has been making excessive long-distance phone calls. When the client can be heard singing loudly in the examining room, the nurse makes initial plans to focus on what? Setting strict limits on dress and behavior Assessing needs for food, liquids, and rest Conducting an in-depth suicide assessment Obtaining a complete psychosocial assessment
Assessing needs for food, liquids, and rest Explanation: Clients with mania frequently ignore basic physiologic needs, as evidenced by not sleeping for 3 days and/or not eating or drinking, thus making these assessments the priority. Nutrition is another area of concern. Manic clients may be too "busy" to sit down and eat, or they may have such poor concentration that they fail to stay interested in food for very long. Limits, although appropriate to consider, are not the priority. The manic state precludes a thorough assessment initially. Suicide assessment is not a priority at this time but reckless behavior could result in personal injury.
A nursing instructor is reviewing a case study with students about a client with mania who was admitted to a mental health unit. The instructor asks the students what medical diagnosis is most likely responsible for the mania. Which would be the best answer by a student? Bipolar disorder Many psychiatric disorders have symptoms of mania Adolescent conduct disorder Anxiety disorder
Bipolar disorder Explanation: In most cases, mania is a symptom that manifests in people with underlying bipolar disorder. Mania is reflected in periods of euphoria, exuberant activity, grandiosity, and a false sense of well-being. There can be periods of mood instability and irritability as well.
The nurse is assessing a client who wants an amputation of the client's healthy left arm. The client feels that the left arm "does not belong" to the body and it feels unnatural. What condition does the nurse identify in this client? Body dysmorphic disorder Major depressive disorder Body identity integrity disorder Illness anxiety disorder
Body identity integrity disorder Explanation: A client who feels alienated from a part of the body and is desiring amputation is identified as having body identity integrity disorder. Clients report feeling "natural" after amputation. The client with body dysmorphic disorder seeks elective surgery to correct slight defects in appearance. The client who suffers from guilt all the time is diagnosed with major depressive disorder. Illness anxiety disorder compels a person to be preoccupied with an imaginary illness.
A 42-year-old client with major depression is in an inpatient psychiatric hospital. The client has been taking phenelzine, a monoamine oxidase inhibitor (MAOI), for depression. The therapist writes an order to discontinue the phenelzine and begin fluoxetine. Which action by the nurse is indicated? Begin educating the client about selective serotonin reuptake inhibitors. Call the therapist to discuss the need for a washout period before starting fluoxetine. Begin educating the client about food restrictions when taking fluoxetine. Note in the medication administration record to check the client's blood pressure for the first 2 days after starting fluoxetine.
Call the therapist to discuss the need for a washout period before starting fluoxetine. Explanation: If the client is switching from an MAOI to fluoxetine, the provider should allow a washout period of at least 5 weeks (half-life of MAOI). Conversely, if a client is switching from fluoxetine to an MAOI, providers should allow a "washout" period of at least 2 weeks (half-life of fluoxetine) before beginning the MAOI.
The nurse is caring for a client who was just admitted with a diagnosis of schizoaffective disorder with depression. Which agent would the nurse anticipate as being prescribed for this client? Lithium Haloperidol Chlorpromazine Clozapine
Clozapine Explanation: Atypical antipsychotic agents are generally prescribed because of their efficacy and safe side effect profile. These agents have a mood-stabilizing, as well as antipsychotic, effect. Clozapine has been reported to be effective for this disorder. Lithium might be an alternative for clients experiencing mood states associated with the bipolar type. Haloperidol and chlorpromazine are typical antipsychotic agents.
A nurse is caring for a client with acute stress disorder. The main goal of therapy for this client is prevention of the progression of this condition to posttraumatic stress disorder (PTSD). Which therapy would the client most likely be referred for? Cognitive behavioral therapy Cognitive processing therapy Exposure therapy Antidepressant drugs
Cognitive behavioral therapy Explanation: Generally, cognitive behavior therapy is given to clients with acute stress disorder to avoid progression to PTSD. Cognitive processing therapy and exposure therapy are specialized treatments given to clients with PTSD to help them overcome problems such as self-blame, guilt, and avoidance behavior. Antidepressants are given to clients to overcome severe depression.
The nurse is studying the medical record of a client who reports blindness. The record indicates there is no ocular abnormality. The client doesn't seem upset by the blindness. What is the client's most likely diagnosis? Hypochondriasis Conversion disorder Optic nerve dysfunction Somatic symptom disorder
Conversion disorder Explanation: The client has no ocular abnormality and isn't distressed by the situation. These findings indicate that the client may have conversion disorder. This involves unexplained, usually sudden deficits in sensory or motor function, such as blindness. Hypochondriasis is condition in which a client is preoccupied with possibly having a disorder or contracting a serious illness. Because all tests for blindness were negative, the client does not have any somatic dysfunction, such as optic nerve dysfunction. Somatic symptom disorder is a condition characterized by one or more physical symptoms that have no organic basis.
A client who otherwise is healthy is admitted for depression and reports feeling "all alone." The client reports recently losing a spouse to divorce. The client admits to drinking at least 12 beers every day. The client has which risk factors for the depression? Select all that apply. Medical comorbodity Current substance use or abuse Life and environmental stressors Lack of coping abilities History of depression
Current substance use or abuse Life and environmental stressors Lack of coping abilities Explanation: Risk factors for depression include prior history of depression, family history of depressive disorder, lack of social support, lack of coping abilities, presence of life and environmental stressors, current substance use or abuse, and medical comorbidity. This client's assessment findings include a recent life stressor in the form of divorce and excessive use of alcohol. In addition, the client's social isolation and heavy drinking indicate lack of healthy coping abilities. The client's data do not include a family history or prior history of depression or any other health issues.
A client is discovered wandering the street, looking confused and stepping out into traffic. When emergency responders approach the client, the client cannot recall the client's name or where the client lives. The responders transport the client to the mental health crisis unit for further evaluation. Which is the client likely potentially suffering from? (Select all that apply.) False memory syndrome Repressed memories Dissociative amnesia Dissociative identity disorder Depersonalization disorder
Depersonalization disorder Dissociative identity disorder Dissociative amnesia Explanation: With dissociative amnesia, the client cannot remember important personal information, such as name or residence. With dissociative personality disorder, the client displays two or more distinct identities or personality states that recurrently take control of his or her behavior; memory lapses would also be associated with this disorder. With depersonalization disorder, the client has a persistent or recurring feeling of being detached from his or her mental processes or body (depersonalization), or has a sensation of being in a dream-like state where the environment seems foggy or unreal (derealization). Wandering aimlessly would be a plausible manifestation of this disorder. Repressed memories are when a person is unable to consciously recall memories of childhood abuse. False memory syndrome can occur during psychotherapy when the client is encouraged to imagine false memories of childhood sexual abuse.
A nurse is conducting a review class on borderline personality disorder. When describing the characteristics associated with this disorder, which would the nurse most likely include? Select all that apply. Difficulty regulating moods Overinflated self-identity Problems with interpersonal relationships Thinking that is based on delusions Impulsive behavior
Difficulty regulating moods Problems with interpersonal relationships Impulsive behavior Explanation: People with BPD have problems regulating their moods, developing a self-identity, maintaining interpersonal relationships, maintaining reality-based thinking, and avoiding impulsive or destructive behavior.
A nurse is caring for a client with posttraumatic stress disorder (PTSD). During the assessment interview, the nurse finds that the normally calm client at times becomes very aggressive and uses abusive language. When in the aggressive state, the client fails to recognize personal information. What is this behavior indicative of? Dissociative amnesia Dissociative identity disorder Depersonalization disorder Avoidance behavior
Dissociative identity disorder Explanation: In dissociative identity disorder, formerly multiple personality disorder, the client displays two or more distinct identities or personality states. Clients in this state have an inability to recall important personal information. In dissociative amnesia, the client cannot remember important personal information. In depersonalization disorder, clients have a persistent or recurrent feeling of being detached from their mental processes or body. Through avoidance behavior, clients with PTSD try to repress any feelings, thoughts, or emotions associated with the traumatic event.
Which is considered a part of the social domain of the biopsychosocial interventions for the client diagnosed with borderline personality disorder (BPD)? Medication administration Establishing boundaries Self-harm prevention Nutritional management
Establishing boundaries Explanation: The social domain includes establishing boundaries as clients with BPD have difficulty maintaining satisfying interpersonal relationships. Medications, prevention of harm to self and others, and encouraging adequate nutrition are part of the biologic domain.
A client diagnosed with anxiety disorder has been prescribed benzodiazepine drugs. The nurse is explaining the possible side effects of the medications. Which side effects of the drug explained by the nurse is correct? Select all that apply. Agitation Dry mouth Blurred vision Constipation Vomiting
Dry mouth Blurred vision Constipation Explanation: Dry mouth, blurred vision, and constipation are known side effects of benzodiazepines. Agitation and vomiting are not known to occur with benzodiazepines. These side effects are associated with nonbenzodiazepine drugs that are used to treat anxiety like buspirone.
As part of a client's treatment plan for borderline personality disorder, the client is engaged in dialectical behavior therapy. As part of the therapy, the client is learning how to control and change extreme behaviors in response to events. The nurse identifies the client as learning which type of skills? Distress tolerance skills Mindfulness skills Reframing Emotion regulation skills
Emotion regulation skills Explanation: Dialectical behavior therapy was designed for clients with borderline personality disorder. It focuses on distorted thinking and behavior based on the assumption that poorly regulated emotions are the underlying problem. Emotional regulation involves recognizing feelings before acting on them in extreme ways, decreasing impulsivity, and learning to delay gratification. The client learns to label and analyze the context of the emotion, as well as to develop strategies to reduce emotional vulnerability. Mindfulness skills are the psychological and behavioral versions of meditation skills usually taught in Eastern spiritual practice; they are used to help the person improve observation, description, and participation skills by learning to focus the mind and awareness on the current moment's activity. Distress tolerance skills involve helping the individual tolerate and accept distress as a part of normal life. Reframing is central to cognitive behavioral therapy; it focuses on looking at distressing events from a different, usually less negative perspective.
A client is prescribed a selective serotonin reuptake inhibitor (SSRI) as treatment for depression. Which would the nurse most likely administer? Escitalopram Venlafaxine Maprotiline Phenelzine
Escitalopram Explanation: Escitalopram is classified as an SSRI. Venlafaxine is classified as a serotonin norepinephrine reuptake inhibitor. Maprotiline is a cyclic antidepressant. Phenelzine is a monoamine oxidase inhibitor.
A client has been diagnosed with depression and states that the client is reluctant to receive treatment, stating that the client "would prefer to just wait this out." What is the nurse's most appropriate action? Document a nursing diagnosis of ineffective denial and choose interventions accordingly Assess the client's knowledge of depression and describe the risks of suicide Document a nursing diagnosis of noncompliance and educate the client about the benefits of treatment Explain to the client that untreated depression often becomes increasingly severe and frequent over time
Explain to the client that untreated depression often becomes increasingly severe and frequent over time Explanation: Untreated depression tends to increase in severity and in the frequency of episodes. The client's statement does not necessarily indicate noncompliance, but rather the client's initial preference. Similarly, the client's statement does not necessarily suggest denial. Assessing the client's knowledge of depression is necessary, but describing the risks of suicide does not directly address the client's expressed preference.
A client is prescribed sertraline for treatment of a somatoform disorder. The nurse would instruct the client to be alert to which side effect? Headache Vomiting Constipation Increased appetite
Headache Explanation: Side effects of sertraline include loss of appetite, diarrhea, nausea, and headache.
A client who is newly admitted to an inpatient unit is exhibiting acute delusional thoughts. The most therapeutic intervention for this client would include what? Group therapy Individual therapy Insight-oriented therapy Problem-oriented therapy
Individual therapy Explanation: Individual psychotherapy is the treatment of choice because clients with delusional thoughts do not respond well to insight-oriented, problem-oriented, or group therapy in which delusions are confronted by peers or therapists. Establishing the therapeutic relationship with the client is the critical first step. Individual therapy would be the most therapeutic intervention for the client's current circumstance.
A client is admitted to a mental health unit with a diagnosis of factitious disorder. When reviewing the client's history, which would a nurse most likely find? Intentional self-injurious behavior Pain to achieve a self-serving goal Malingering to avoid work Parents who were restrictive
Intentional self-injurious behavior Explanation: Clients with factitious disorder intentionally cause an illness or injury to receive the attention of health care professionals. Pain for a self-serving goal, malingering, or restrictive parents are not associated with factitious disorder.
A nurse is providing care to a client with antisocial personality disorder. As part of the plan of care, the client is to participate in a problem-solving group. The nurse understands that this intervention is effective based on which rationale? It requires the client to develop attachments. It sets up specific boundaries for the client. It helps to reinforce self-responsibility. It avoids confrontation about dysfunctional patterns.
It helps to reinforce self-responsibility. Explanation: Problem-solving groups that focus on identifying a problem and developing a variety of alternative solutions are especially helpful for a client with antisocial personality disorder. This is because client self-responsibility is reinforced when clients remind each other of better alternatives. In addition, clients are likely to confront each other with dysfunctional schemas or thinking patterns. Groups that focus on developing empathy would foster attachment. Although groups typically have specific rules and boundaries, this is not the primary focus of problem-solving groups.
A psychiatric-mental health nurse is conducting a suicide assessment with a client. Why is it important to conduct a lethality assessment? It may assist in determining an individual's past suicide behaviors. It may assist in determining how long a client has been contemplating suicide. It may assist in evaluating the potential suicide protective factors of a client. It may assist in predicting how likely a person is to die by suicide.
It may assist in predicting how likely a person is to die by suicide. Explanation: Lethality assessment is part of conducting a risk assessment. Once it is determined that someone is thinking of suicide, a lethality assessment is necessary. It is an attempt to predict how likely a person is to die by suicide.
When developing the plan of care for a client with somatic symptom disorder, which would be the most important yet most difficult intervention for the nurse to implement? Maintaining a therapeutic relationship Discussing results of diagnostic tests Assisting with problem solving Educating the client about positive health care practices
Maintaining a therapeutic relationship Explanation: Although discussing the results of diagnostic tests, assisting with problem solving, and teaching the client about health are important interventions addressing the psychological domain, the most difficult aspect is developing a sound, positive nurse-client relationship. This relationship is crucial.
The nurse is developing a plan for group therapy sessions for several adult clients with schizophrenia. Which goal is best for this group? Members will gain insight into unconscious factors that contribute to their illness. Members will demonstrate adaptive social skills. Members will explore situations that trigger hostility and anger. Members will learn to manage delusional thinking.
Members will demonstrate adaptive social skills. Explanation: Group therapy sessions focus on social skills, concentrating on appropriate interpersonal interaction. The therapist role plays with the client, modeling and identifying suitable social actions and responses.
Which should the nurse anticipate when providing therapy and evaluating outcomes for a client with delusional disorder? Easily attained Maintained for a short period only Achieved when delusions completely disappear within 6 months' time Often not met completely
Often not met completely Explanation: In evaluating progress, the nurse must remember that outcomes are often not met completely.
The nurse explains to the client that therapy will be a long process. Which is a realistic outcome for the care of a person with a personality disorder? Outcomes that focus on satisfaction with daily life Outcomes that focus on the client's perception of others Outcomes that focus on increased client insight Outcomes that focus on change in behavior
Outcomes that focus on change in behavior Explanation: The treatment focus often is behavioral change. Although treatment is unlikely to affect the client's insight or view of the world and others, it is possible to make changes in behavior. Behavioral change is prioritized because it is the tangible outcome that directly affects the client's interactions with others. Changes in insight, satisfaction and perception of others have little value unless they result in observable changes in the way the client interacts with others.
A client with a diagnosis of schizophrenia believes that the client is an undercover operative for the Central Intelligence Agency and that voices of various representatives of the organization give the client regular updates on the client's missions. The client is unwilling to participate in many interventions because the client is "too busy with things that are more important than you could possibly understand." The primary theme of the client's delusions is consistent with what? Paranoia Catatonia Disorganization Undifferentiation
Paranoia Explanation: Clients with a diagnosis of schizophrenia who exhibit paranoid delusions tend to experience persecutory or grandiose delusions and auditory hallucinations.
A client with major depression and a suicide attempt is admitted to the inpatient facility. The client is started on antidepressant therapy. The next day, the client demonstrates significantly higher energy and says, "I'll feel much better." The nurse would interpret this behavior as suggesting what? - Effectiveness of the drug therapy - Possible decision to complete a suicide attempt - An act to cover up the client's true feelings - A typical response to the medication
Possible decision to complete a suicide attempt Explanation: In many cases, clients are admitted to the psychiatric hospital because of a suicide attempt. Suicidality should continually be evaluated, and the client should be protected from self-harm. During the depths of depression, clients may not have the energy to complete a suicide. As clients begin to feel better and have increased energy, they may be at a greater risk for suicide. If a previously depressed client appears to become energized overnight, he or she may have made a decision to commit suicide and thus may be relieved that the decision is finally made. The nurse may misinterpret the mood improvement as a positive move toward recovery; however, this client may be very intent on suicide. These individuals should be carefully monitored to maintain their safety. Antidepressants take several weeks to become effective.
The nurse is teaching a client with an anxiety disorder ways to manage anxiety. The nurse suggests which schedule for practicing relaxation techniques? Reserve these techniques for episodes of panic. Use the techniques as needed when experiencing severe anxiety. Practice the techniques when relatively calm. Expect to practice the techniques when meeting with a therapist.
Practice the techniques when relatively calm. Explanation: The nurse can teach the client relaxation techniques to use when he or she is experiencing stress or anxiety, including deep breathing, guided imagery and progressive relaxation, and cognitive restructuring techniques. For any of these techniques, it is important for the client to learn and to practice them when he or she is relatively calm. These techniques are most effective when implemented before the client's anxiety reaches a severe level or a panic. The client may be taught these techniques by a therapist but does not usually have an opportunity to practice them during a therapy session.
A client has been admitted to a psychiatric-mental health facility in a manic state. The client's spouse accompanies the client to the facility and informs the nurse that the client has been displaying manic symptoms for the past 2 weeks. The spouse reports that the client has not slept for the past 2 days and that the client has not eaten anything for at least 3 days. Which would be the priority nursing diagnosis for this client? Ineffective health maintenance Risk for other-directed violence Risk for imbalanced nutrition Risk for suicide
Risk for imbalanced nutrition Explanation: A primary concern for clients with bipolar disorders is physiologic integrity and function. Mania causes hyperactivity, resulting in an inability to sit still for the time needed to eat a meal. Clients with mania often neglect nutritional and fluid needs. While all listed nursing diagnoses are appropriate for the client, restoring nutritional balance is the highest priority.
Following a long history of multiple visits to community clinics and emergency departments, a client has been diagnosed with hypochondriasis. During this current visit to the emergency department, the client has just been informed that diagnostic testing and assessment reveal no severe illness. Despite this, the client persists in verbalizing physical complaints. How should the nurse respond to this? Have a different member of the care team present the test and assessment results to the client. Facilitate a repeat of the previous diagnostic testing in order to appease the client. Set limits with the client about the complaints. Feign an assessment of the client in order to calm the client's anxiety.
Set limits with the client about the complaints. Explanation: If a client with the diagnosis of hypochondriasis has been told that the client has no life-threatening or severe illnesses, but the client continues to verbalize clinical symptoms, limit-setting is used. A "false" assessment is unethical, and repeating diagnostic testing reinforces the client's behavior. Having diagnostic results presented by another member of the care team is unlikely to eliminate the client's concerns.
A client with depression appears lethargic and apathetic but agrees to participate in a leisure activity group. Which nursing intervention is most likely to help the client successfully participate? Allowing the client to direct participation at the client's own pace Giving the client several choices of projects so the client can choose a favorite Staying away from the client during the session to encourage free expression Structuring the activity to facilitate completion of one specific task
Structuring the activity to facilitate completion of one specific task Explanation: Clients who are depressed may find decision-making and multitasking stressful and overwhelming. It is therapeutic for the nurse to help the client focus his or her pace and efforts on a specific, achievable task. The client will likely benefit from the nurse empathically and respectfully pushing her to achieve. Ignoring the client does not help her make achievements and participate more actively.
The psychiatric nurse managing the care of a client experiencing alcohol withdrawal instructs unit staff to anticipate that the client may experience which neurological response? - Tactile hallucinations - Gustatory hallucinations - Somatic delusions - Nihilistic delusions
Tactile hallucinations Explanation: Alcohol withdrawal can be the origin of tactile hallucinations. Alcohol withdrawal is not usually the origin of gustatory hallucinations or delusions of any type.
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? B e the client's primary thought process throughout the entire day. Cause considerable anguish if not performed first thing in the morning. Take up more than 1 hour/day and cause stress to the client. Convince the client that the obsessive thoughts are true.
Take up more than 1 hour/day and cause stress to the client. Explanation: 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.
Which is an appropriate intervention for a client having auditory hallucinations? Discourage the client from discussing the content of the hallucinations with anyone else. Mildly admonish the client for the hallucinations. Encourage the client to spend quiet time alone until hallucinations cease. Tell the client to talk back to the voices and tell them to go away.
Tell the client to talk back to the voices and tell them to go away. Explanation: Interventions for managing hallucinations include dismissal intervention (i.e., telling the voices to go away), various coping strategies (e.g., jogging, telephoning, playing games, seeking out others, employing relaxation techniques), or competing stimuli (e.g., listening to music or the voice of oneself or another to overcome auditory hallucinations and using visual stimuli to overcome visual hallucinations). Some clients desire to discuss their hallucinations with health care staff to gain understanding. In any event, the nurse may elicit a description of the hallucination to seek understanding of how to calm or reassure the client, protecting the client and others. While the nurse should never endorse a hallucination as real, the nurse should also not scold the client for having hallucinations. Isolation is not helpful for the client with hallucinations; the nurse should help maintain reality through frequent contact with client, and the client should be engaged in reality-based activities and reintegrated into the treatment milieu as soon as possible.
A nurse finds that a client with posttraumatic stress disorder (PTSD) is behaving abnormally and suspects that the client has had a flashback of the traumatic event. Which behavioral manifestations of the client would lead the nurse to make this interpretation? Select all that apply. The client appears terrified. The client is crying loudly. The client complains of severe pain. The client looks extremely fatigued. The client attempted to run away.
The client appears terrified. The client is crying loudly. The client attempted to run away. Explanation: A client with PTSD usually has dreams, nightmares, and flashbacks associated with the traumatic event that cause intense distress. A client who has had a flashback of the traumatic event appears terrified, may cry or scream, or may attempt to hide or run away. Pain and fatigue are not symptoms related to having a flashback.
A client with conversion disorder talks at length about a loss of vision. The nurse talks to the client about good hygiene practices and encourages the client to talk about any topic of interest. What is the nurse's intention for this intervention? Choose the best answer. The client should express the physical problem to the nurse. The client should pay less attention to the physical problem. The client should adopt good hygienic practices. The client should feel comfortable with the nurse.
The client should pay less attention to the physical problem. Explanation: By discussing good hygiene practices and encouraging the client to speak on any topic of interest, the nurse is trying to avoid discussing the client's physical symptom. The client with conversion disorder may have good hygiene habits; the nurse is not trying to teach the client about good hygiene habits. The nurse's intervention is not aimed at making the client feel comfortable with the nurse or to make the client express the physical problems. The purpose of the nurse's intervention is to help minimize secondary gain and decrease the client's focus on the symptom.
Which goal is appropriate for the client being treated for obsessive-compulsive disorder with response prevention therapy? The client will demonstrate an understanding of the benefits of deep breathing within 2 days. The client will experience notably less anxiety when engaged in delaying the ritual within 3 months. The client will implement relaxation techniques to help manage his or her anxiety within 2 days. The client will deliberately confront the trigger of his or her anxiety within 3 months.
The client will experience notably less anxiety when engaged in delaying the ritual within 3 months. Explanation: Response prevention focuses on delaying or avoiding performance of rituals. The client learns to tolerate the thoughts and the anxiety and to recognize that it will recede without the disastrous imagined consequences. Other techniques, such as deep breathing and relaxation, can also assist the person to tolerate and eventually manage the anxiety. Exposure involves assisting the client to deliberately confront the situations and stimuli that he or she usually avoids.
The nurse is identifying outcomes for a client with a somatic symptom illness. Which is an appropriate outcome to include in the plan of care? The client will verbally express his or her emotions. The client will be free from stress. The client will demonstrate alternative ways to avoid stressful situations. The client will verbalize acceptance of physical symptoms.
The client will verbally express his or her emotions. Explanation: Treatment outcomes for clients with a somatic symptom illness may include the following: the client will identify the relationship between stress and physical symptoms; the client will verbally express emotional feelings; the client will follow an established daily routine; the client will demonstrate alternative ways to deal with stress, anxiety, and other feelings; the client will demonstrate healthier behaviors regarding rest, activity, and nutritional intake. It is unrealistic for the client to be free from stress or to avoid stressors as a means of managing the disorder. Treatment focuses on promoting the client's coping, not simply accepting the physical symptoms that accompany the disorder. Accepting the physical symptoms would suggest ineffective treatment because the goal is to relieve the symptoms by addressing the underlying psychology.
The nursing student correctly identifies that which statements are true of the etiology of obsessive-compulsive disorder (OCD)? (Select all that apply.) - The cognitive model for OCD etiology focuses on childhood and environmental experiences of growing up. - The etiology of OCD is not definitively explained at this time. - Cognitive models may partially explain why people develop OCD. - OCD is caused by immune dysfunction. - The primary etiology of OCD is genetics.
The cognitive model for OCD etiology focuses on childhood and environmental experiences of growing up. The etiology of OCD is not definitively explained at this time. Cognitive models may partially explain why people develop OCD. Explanation: Different studies of the etiology of OCD show promise but have yet to definitively explain how or why people develop OCD. Cognitive models of OCD have been long accepted as a partial explanation for OCD. The cognitive model focuses on childhood and environmental experiences of growing up. Heritable, genetic factors are a significant influence on thinking, and environmental influences are not solely responsible. Immune dysfunction may play a role in the etiology of OCD but this has not been definitively confirmed.
After teaching a group of nursing students about somatic symptom disorder (SSD), the instructor determines that additional education is necessary when the group identifies which statement as true? The condition is characterized by multiple physical symptoms. The condition is an acute short-term condition. The age of onset is usually before age 30 years. The disorder includes a combination of pain and gastrointestinal, sexual, and pseudoneurologic symptoms.
The condition is an acute short-term condition. Explanation: The disorder is not acute. SSD is one of the most difficult disorders to manage because the symptoms tend to change, are diffuse and complex, and vary and move from one body system to another. For example, initially there may be gastrointestinal (nausea, vomiting, diarrhea) and neurologic (headache, backache) symptoms that change to musculoskeletal (aching legs) and sexual issues (pain in the abdomen, pain during intercourse). The physical symptoms may last for 6 to 9 months.
In speaking with a client with moderate anxiety, the client becomes tangential discussing unrelated topics. To help the client's attention from wandering, which is an effective intervention? The nurse should speak in short and simple sentences. The nurse should remain with the client until the anxiety is reduced. The nurse should speak in a soft and calm voice. The nurse should take the client to a nonstimulating environment.
The nurse should speak in short and simple sentences. Explanation: Speaking in short, simple, and easy-to-understand sentences has been shown to be effective with clients with moderate anxiety whose attention wanders. Not leaving the client alone unless the anxiety is reduced and speaking in a soft voice are interventions used with a client with severe anxiety. If the client has panic-level anxiety, the nurse should give primary attention to the safety of the client and move the client to a nonstimulating environment.
Which are central components of a psychiatric rehabilitation and recovery program? Select all that apply. Working with clients to have an improved quality of life according to society's point of view Working with clients to manage their own lives Working with clients to make effective treatment decisions Working with clients to have an improved quality of life according to his or her point of view Working with clients to diagnose their problem early
Working with clients to manage their own lives Working with clients to make effective treatment decisions Working with clients to have an improved quality of life according to his or her point of view Explanation: Psychiatric rehabilitation has the goal of recovery for clients with major mental illness that goes beyond symptom control and medication management. Working with clients to manage their own lives, make effective treatment decisions, and have an improved quality of life -- from the client's point of view -- are central components of such programs. Diagnosis occurs near the beginning of care; rehabilitation and recovery are ongoing components of care that occur after the initial diagnosis and treatment. Quality of life is defined subjectively and may or may not align with social norms.
Which nursing assessment is most appropriate for an older client presenting with reports of generalized anxiety? assess for depression assess for panic attacks assess for elder abuse assess for dementia
assess for depression Explanation: Late-onset generalized anxiety disorder (GAD) is usually associated with depression. Although less common, panic attacks can occur in later life and are often related to depression or a physical illness such as cardiovascular, GI, or chronic pulmonary diseases. While the remaining options are appropriate, they are not associated with the possible comorbid conditions of GAD.
The nurse is caring for a client with schizoaffective disorder with depression. The nurse should instruct the client that the most effective medication therapy for this disorder is: mood-stabilizing medications. antipsychotic medications combined with lithium. antidepressant medications. atypical antipsychotic medications.
atypical antipsychotic medications. Explanation: Atypical antipsychotic medications may have mood stabilizing effects as well as antipsychotic effects; in many cases, symptoms of depression disappear when the psychotic symptoms decrease.
A client with schizoaffective disorder is prescribed medication therapy. Which type of medications would be most likely be ordered? atypical antipsychotics typical antipsychotics antidepressants mood stabilizers
atypical antipsychotics Explanation: Although numerous drugs may be prescribed, atypical antipsychotics are generally prescribed because of their efficacy for psychosis and for their thymoleptic (mood stabilizing) properties. Atypical antipsychotics have been used more often than typical antipsychotics. If depressive symptoms persist despite antipsychotic use, antidepressants may be prescribed. Mood stabilizers are an alternative adjunct for mood states associated with the bipolar type of the disorder.
A nurse taking an admission history from a client suspects that the physician will diagnose major depression. For the physician to make this diagnosis, the client will have to demonstrate specific symptoms. What are some of these symptoms? Select all that apply. disruption in sleep disruption in appetite obsessive desire to exercise disruption in concentration excessive guilt
disruption in sleep disruption in appetite disruption in concentration excessive guilt Explanation: Four of seven symptoms must be present along with the episodes of depressed mood to qualify for a diagnosis of major depressive disorder. Symptoms include disruption in sleep, appetite, concentration, or energy; psychomotor agitation or retardation; excessive guilt or feelings of worthlessness; and suicidal ideation.
A nurse is caring for a client with obsessive-compulsive disorder who continually checks appliances to be sure the appliances are turned off. Which areas should the nurse address in the plan of care? Select all that apply. an alternative activity such as cleaning the kitchen skin care measures to prevent skin breakdown relaxation techniques such as deep breathing cognitive restructuring for dysfunctional thoughts thought stopping when having obsessional thoughts
relaxation techniques such as deep breathing cognitive restructuring for dysfunctional thoughts thought stopping when having obsessional thoughts Explanation: Treatment of obsessive-compulsive disorder involves multiple measures including: relaxation techniques, which help with decrease of anxiety, cognitive restructuring which helps with defining and testing obsessive thoughts so that the client understands these are dysfunctional; and thought-stopping which helps interrupt obsessional thoughts. Cleaning the kitchen as an alternative activity is not a good plan because it involves repeated exposure to appliances. Skin care measures may be indicated for some compulsions but not checking appliances.
