Mental Health Final

A nurse observes dental deterioration when assessing a client diagnosed with bulimia nervosa. What explains this assessment finding? A. The emesis produced during purging is acidic and corrodes the tooth enamel. B. Purging causes the depletion of dietary calcium. C. Food is rapidly ingested without proper mastication. D. Poor dental and oral hygiene leads to dental caries.

ANS: A The nurse recognizes that dental deterioration has resulted from the acidic emesis produced during purging that corrodes the tooth enamel. Excessive vomiting may also lead to dehydration and electrolyte imbalance.

Which statement should indicate to a nurse that an individual is experiencing a delusion? A. "There's an alien growing in my liver." B. "I see my dead husband everywhere I go." C. "The IRS may audit my taxes." D. "I'm not going to eat my food. It smells like brimstone."

ANS: A The nurse should recognize that a client who claims that an alien is inside his or her body is experiencing a delusion. Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background.

An adolescent client has problems expressing anger appropriately. Which nursing statement would encourage the client to set realistic goals? A. "What do you think needs to change about how you express anger?" B. "How did you feel after attending the anger management session?" C. "On a scale of 1 to 10, please rate your current level of anger." D. "What bothers you about the actions of others when you get angry?"

ANS: A In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client or to the situation.

A client has been brought to the emergency department for signs and symptoms of Chronic Obstructive Pulmonary Disease (COPD). The client has a history of a suicide attempt 1 year ago. Which nursing intervention would take priority in this situation? A. Assessing the client's pulse oximetry and vital signs B. Developing a plan for safety for the client C. Assessing the client for suicidal ideations D. Establishing a trusting nurse-client relationship

ANS: A It is important to prioritize client interventions that assess the symptoms of COPD prior to any other nursing intervention. Physical needs must be prioritized according to Maslow's hierarchy of needs. This client's problems with oxygenation will take priority over assessing for current suicidal ideations.

Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder? A. Being firm, consistent, and empathic, while addressing specific client behaviors B. Promoting client self-expression by implementing laissez-faire leadership C. Using authoritative leadership to help clients learn to conform to society norms D. Overlooking inappropriate behaviors to avoid promoting secondary gains

ANS: A The best nursing approach when working with a client diagnosed with borderline personality disorder is to be firm, consistent, and empathetic while addressing specific client behaviors. Individuals diagnosed with borderline personality disorder always seem to be in a state of crisis and can often have negative patterns of interaction such as manipulation and splitting.

A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions? A. "I will need scheduled blood work in order to monitor for toxic levels of this drug." B. "I won't stop taking this medication abruptly because there could be serious complications." C. "I will not drink alcohol while taking this medication." D. "I won't take extra doses of this drug because I can become addicted."

ANS: A The client indicates a need for additional information about taking benzodiazepines when stating the need for blood work to monitor for toxic levels. No blood work is needed when taking a short-acting benzodiazepine. The client should understand that taking extra doses of a benzodiazepine may result in addiction and that the drug should not be taken in conjunction with alcohol.

A client diagnosed with chronic alcohol dependency is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching? A. After discharge, the client will immediately attend 90 AA meetings in 90 days. B. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. C. After discharge, the client will incorporate family in AA attendance. D. After discharge, the client will seek appropriate deterrent medications through AA.

ANS: A The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. It accepts alcoholism as an illness and promotes total abstinence as the only cure.

A client diagnosed with panic disorder states, "When an attack happens, I feel like I am going to die." Which is the most appropriate nursing reply? A. "I know it's frightening, but try to remind yourself that this will only last a short time." B. "Death from a panic attack happens so infrequently that there is no need to worry." C. "Most people who experience panic attacks have feelings of impending doom." D. "Tell me why you think you are going to die every time you have a panic attack."

ANS: A The most appropriate nursing reply to the client's concerns is to empathize with the client and provide encouragement that panic attacks last only a short period. Panic attacks usually last minutes but can, rarely, last hours. Symptoms of depression are also common with this disorder.

Which statement made by an emergency department nurse indicates accurate knowledge of domestic violence? A. "Power and control are central to the dynamic of domestic violence." B. "Poor communication and social isolation are central to the dynamic of domestic violence." C. "Erratic relationships and vulnerability are central to the dynamic of domestic violence." D. "Emotional injury and learned helplessness are central to the dynamic of domestic violence."

ANS: A The nurse accurately states that power and control are central to the dynamic of domestic violence. Battering is defined as a pattern of coercive control founded on physical and/or sexual violence or threat of violence. The typical abuser is very possessive and perceives the victim as a possession.

A kindergarten student is frequently violent toward other children. A school nurse notices bruises and burns on the child's face and arms. What other symptom should indicate to the nurse that the child might have been physically abused? A. The child shrinks at the approach of adults. B. The child begs or steals food or money. C. The child is frequently absent from school. D. The child is delayed in physical and emotional development.

ANS: A The nurse should determine that a child who shrinks at the approach of adults in addition to having bruises and burns might be a victim of abuse. Whether or not the adult intended to harm the child, maltreatment should be considered.

A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms? A. Between 3 a.m. and 11 a.m. B. Shortly after a 24-hour period C. At the beginning of the third day D. Withdrawal is individualized and cannot be predicted.

ANS: A The nurse should expect that this client will begin experiencing withdrawal symptoms from alcohol between 3 a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or reduction in heavy and prolonged alcohol use.

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately? A. Sore throat, fever, and malaise B. Akathisia and hypersalivation C. Akinesia and insomnia D. Dry mouth and urinary retention

ANS: A The nurse should intervene immediately if the client experiences a sore throat, fever, and malaise when taking the atypical antipsychotic drug clozapine (Clozaril). Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur. Symptoms of infectious processes would alert the nurse to this potential.

A nursing instructor is teaching students about the differences between the symptoms of anorexia nervosa and the symptoms of bulimia nervosa. Which student statement indicates that learning has occurred? A. "Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not." B. "Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not." C. "Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not." D. "Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not."

ANS: A The nursing student statement that clients diagnosed with anorexia nervosa experience nutritional deficits, whereas clients diagnosed with bulimia nervosa do not, indicates that learning has occurred. Anorexia is characterized by low caloric and nutritional intake. Bulimia is characterized by episodic, rapid indigestion of large quantities of food followed by purging.

A couple is in counseling related to their dysfunctional relationship. Their daughter has recently made a suicide gesture. The nurse should recognize that this might be an example of which family system concept? A. Triangulation B. Pseudohostility C. Double-bind communication D. Pseudomutuality

ANS: A Triangulation occurs when a relationship between two people is dysfunctional. A third person is brought into the relationship to help stabilize it. The couple is triangulating with their daughter. The threatened daughter draws attention from her parent's interpersonal conflicts by her own dysfunctional behavior.

A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this client's symptoms? (Select all that apply.) A. Encourage the client to recognize the signs of escalating anxiety. B. Encourage the client to avoid any situation that causes stress. C. Encourage the client to employ newly learned relaxation techniques. D. Encourage the client to cognitively reframe thoughts about situations that generate anxiety. E. Encourage the client to avoid caffeinated products.

ANS: A, C, D, E Nursing interventions that address GAD symptoms should include encouraging the client to recognize signs of escalating anxiety, to employ relaxation techniques, to cognitively reframe thoughts about anxiety-provoking situations, and to avoid caffeinated products. Avoiding situations that cause stress is not an appropriate intervention because avoidance does not help the client overcome anxiety. Stress is a component of life and is not easily evaded.

A college student has been diagnosed with generalized anxiety disorder (GAD). Which of the following symptoms should a campus nurse expect this client to exhibit? (Select all that apply.) A. Fatigue B. Anorexia C. Hyperventilation D. Insomnia E. Irritability

ANS: A, D, E The nurse should expect that a client diagnosed with GAD would experience fatigue, insomnia, and irritability. GAD is characterized by chronic, unrealistic, and excessive anxiety and worry.

After disturbing the peace, an aggressive, disoriented, unkempt, homeless individual is escorted to an emergency department by police. The client threatens suicide. Which criteria would enable a physician to consider involuntary commitment? (Select all that apply.) A. Being dangerous to others B. Being homeless C. Being disruptive to the community D. Being gravely disabled and unable to meet basic needs E. Being suicidal

ANS: A, D, E The physician could consider involuntary commitment when a client is being dangerous to others, is gravely disabled, or is suicidal. If the client is determined to be mentally incompetent, consent should be obtained from the legal guardian or court-approved guardian or conservator. A hospital administrator may give permission for involuntary commitment when time does not permit court intervention.

An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. "We'll go to the day room when you are ready for group." B. "I'll walk with you to the day room. Group is about to start." C. "It must be difficult for you to attend group when you feel so bad." D. "Let me tell you about the benefits of attending this group."

ANS: B A client diagnosed with major depressive disorder exhibits little to no motivation and must be firmly directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff.

Which nursing intervention is appropriate when caring for clients diagnosed with either anorexia nervosa or bulimia nervosa? A. Provide privacy during meals. B. Remain with the client for at least 1 hour after the meal. C. Encourage the client to keep a journal to document types of food consumed. D. Restrict client privileges when provided food is not completely consumed.

ANS: B A nurse should remain with clients diagnosed with either anorexia nervosa or bulimia nervosa for at least 1 hour after meals. This allows the nurse to monitor for food discarding (anorexia nervosa) and/or self-induced vomiting (bulimia nervosa).

A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder? A. Altered communication R/T feelings of worthlessness AEB anhedonia B. Social isolation R/T poor self-esteem AEB secluding self in room C. Altered thought processes R/T hopelessness AEB persecutory delusions D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

ANS: B A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming.

Which is an example of an intentional tort? A. A nurse fails to assess a client's obvious symptoms of neuroleptic malignant syndrome. B. A nurse physically places an irritating client in four-point restraints. C. A nurse makes a medication error and does not report the incident. D. A nurse gives patient information to an unauthorized person.

ANS: B A tort is a violation of civil law in which an individual has been wronged and can be intentional or unintentional. A nurse who physically places an irritating client in restraints has touched the client without consent and has committed an intentional tort.

A client has been extremely nervous ever since a person died as a result of the client's drunk driving. When assessing for the diagnosis of adjustment disorder, within what timeframe should the nurse expect the client to exhibit these symptoms? A. To meet the DSM-IV criteria for adjustment disorder, the client should exhibit symptoms within 1 year of the accident. B. To meet the DSM-IV criteria for adjustment disorder, the client should exhibit symptoms within 3 months of the accident. C. To meet the DSM-IV criteria for adjustment disorder, the client should exhibit symptoms within 6 months of the accident. D. To meet the DSM-IV criteria for adjustment disorder, the client should exhibit symptoms within 9 months of the accident.

ANS: B According to the DSM-IV diagnostic criteria for adjustment disorders, the development of emotional or behavioral symptoms in response to an identifiable stressor occurs within 3 months of the onset of the stressor.

A nurse is caring for a client who is suspected of having the diagnosis of trichotillomania. What condition must be ruled out prior to a definitive diagnosis of this disorder? A. Bipolar disorder B. Alopecia areata C. Post-traumatic stress disorder D. Body dysmorphic disorder

ANS: B Alopecia areata is a dermatological condition that, according to the DSM-IV diagnostic criteria for trichotillomania, must be ruled out to establish this diagnosis.

A client who is 5 foot 6 inches tall and weighs 98 pounds is admitted with a medical diagnosis of anorexia nervosa. Which nursing diagnosis would take priority at this time? A. Ineffective coping R/T food obsession B. Altered nutrition: less than body requirements R/T inadequate food intake C. Risk for injury R/T suicidal tendencies D. Altered body image R/T perceived obesity

ANS: B Based on Maslow's hierarchy, the priority nursing diagnosis for this client must address physical needs prior to emotional considerations. This client must be immediately physically stabilized due to the life-threatening nature of his or her nutritional status.

A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. "I cannot drink any alcohol with this medication." B. "It is going to take 2 to 3 weeks in order for me to begin to feel better." C. "This drug causes physical dependence and I need to strictly follow doctor's orders." D. "I can't take this medication with food. It needs to be taken on an empty stomach."

ANS: B Buspar takes at least 2 to 3 weeks to be effective in controlling symptoms of depression. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective.

In assessing a client diagnosed with polysubstance abuse, the nurse should recognize that withdrawal from which substance may require a life-saving emergency intervention? A. Dextroamphetamine (Dexedrine) B. Diazepam (Valium) C. Morphine (Astramorph) D. Phencyclidine (PCP)

ANS: B If large doses of central nervous system (CNS) depressants (like Valium) are repeatedly administered over a prolonged duration, a period of CNS hyperexcitability occurs on withdrawal of the drug. The response can be quite severe, even leading to convulsions and death.

The nurse should recognize which factors that distinguish personality disorders from psychosis? A. Functioning is more limited in personality disorders than in psychosis. B. Major disturbances of thought are absent in personality disorders. C. Personality disordered clients require hospitalization more frequently. D. Personality disorders do not affect family relationships as much as psychosis.

ANS: B Major disturbances of thought are absent in personality disorders and are a classic symptom of psychosis.

Which is the priority nursing intervention for a client admitted for acute alcohol intoxication? A. Darken the room to reduce stimuli in order to prevent seizures. B. Assess aggressive behaviors in order to intervene to prevent injury to self or others. C. Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system. D. Teach the negative effects of alcohol on the body.

ANS: B Symptoms associated with the syndrome of alcohol intoxication include but are not limited to aggressiveness, impaired judgment, impaired attention, and irritability. Safety is a nursing priority in this situation.

Within the nurse's scope of practice, which function is exclusive to the advance practice psychiatric nurse? A. Teaching about the side effects of neuroleptic medications B. Using psychotherapy to improve mental health status C. Using milieu therapy to structure a therapeutic environment D. Providing case management to coordinate continuity of health services

ANS: B The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. It is within the scope of practice of a registered psychiatric mental health nurse generalist to provide education, case management, and milieu therapy.

A 52-year-old client states, "My husband is upset because I don't enjoy sex as much as I used to." Which priority client data should a nurse initially collect? A. History of hysterectomy B. Date of last menstrual cycle C. Use of birth control methods D. History of thought disorder

ANS: B The nurse should assess the client's last menstrual cycle to determine if the client is experiencing the onset of menopause. Menopause usually occurs around the age of 50. The decrease in estrogen can result in multiple symptoms including a decrease in biological drives and sexual activity.

When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit? A. The use of highly lethal methods to commit suicide B. The use of suicidal gestures to evoke a rescue response from others C. The use of isolation and starvation as suicidal methods D. The use of self-mutilation to decrease endorphins in the body

ANS: B The nurse should expect that a client diagnosed with borderline personality disorder might use suicidal gestures to evoke a rescue response from others. Repetitive, self-mutilative behaviors are common in clients diagnosed with borderline personality disorders. These behaviors are generated by feelings of abandonment following separation from significant others.

What is the best rationale for including the client's family in therapy within the inpatient milieu? A. To structure a program of social and work-related activities B. To facilitate discharge from the hospital C. To provide a concrete demonstration of caring D. To encourage the family to model positive behaviors

ANS: B The nurse should include the client's family in therapy within the inpatient milieu to facilitate discharge from the hospital. Family members are invited to participate in some therapy groups and to share meals with the client in the communal dining room. Family involvement may also serve to prevent the client from becoming too dependent on the therapeutic environment.

A college student has quit attending classes, isolates self due to hearing voices, and yells accusations at fellow students. Based on this information, which nursing diagnosis should the nurse prioritize? A. Altered thought processes R/T hearing voices AEB increased anxiety B. Risk for other-directed violence R/T yelling accusations C. Social isolation R/T paranoia AEB absence from classes D. Risk for self-directed violence R/T depressed mood

ANS: B The nursing diagnosis that must be prioritized in this situation should be risk for other-directed violence R/T yelling accusations. Hearing voices and yelling accusations indicates a potential for violence, and this potential safety issue should be prioritized.

A nursing instructor is teaching about specific phobias. Which student statement should indicate that learning has occurred? A. "These clients do not recognize that their fear is excessive and rarely seek treatment." B. "These clients have a panic level of fear that is overwhelming and unreasonable." C. "These clients experience symptoms that mirror a cerebrovascular accident (CVA)." D. "These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis."

ANS: B The nursing instructor should evaluate that learning has occurred when the student knows that clients experiencing phobias have a panic level of fear that is overwhelming and unreasonable. Phobia is fear cued by a specific object or situation in which exposure to the stimuli produces an immediate anxiety response.

After years of dialysis, an 84-year-old states, "I'm exhausted, depressed, and so over these attempts to keep me alive." Which question should the nurse ask the spouse when preparing a discharge plan of care? A. "Has there been had any appetite or sleep changes?" B. "How often is your spouse left alone?" C. "Has your spouse been following a diet and exercise program consistently?" D. "How would you characterize your relationship with your spouse?"

ANS: B This client has many risk factors for suicide. The client should have increased supervision to decrease likelihood of self-harm.

A nursing instructor is teaching about suicide in the elderly population. Which information should the instructor include? A. Elderly people use less lethal means to commit suicide. B. While the elderly make up less than 13% of the population, they account for 16% of all suicides. C. Suicide is the second leading cause of death in the elderly. D. It is normal for elderly individuals to express a desire to die because they have come to terms with their mortality.

ANS: B This factual information should be included in the nursing instructor's teaching plan. An expressed desire to die is not normal in any age group.

Which nursing statement is a good example of the therapeutic communication technique of offering self? A. "I think it would be great if you talked about that problem during our next group session." B. "Would you like me to accompany you to your electroconvulsive therapy treatment?" C. "I notice that you are offering help to other peers in the milieu." D. "After discharge, would you like to meet me for lunch to review your outpatient progress?"

ANS: B This is an example of the therapeutic communication technique of offering self. Offering self makes the nurse available on an unconditional basis, increasing client's feelings of self-worth. Professional boundaries must be maintained when using the technique of offering self.

After hearing parents discuss divorce, a 5-year-old develops behavioral problems. Upon dealing with the child's behavioral issues, the marital relationship conflict decreases. The pediatric clinic nurse should recognize that this is an example of which family system concept? A. Differentiation of self B. Triangulation C. Fusion D. Emotional cutoff

ANS: B Triangulation occurs when a relationship between two people is dysfunctional so a third person is brought into the relationship to help stabilize it. The son and his behavioral problems redirect the focus from the couple's marital problems.

A nursing instructor is teaching about the various categories of paraphilia. Which of the following categories are correctly matched with expected behaviors? (Select all that apply.) A. Exhibitionism: Mary models lingerie for a company that specializes in home parties. B. Voyeurism: John is arrested for peering in a neighbor's bathroom window. C. Frotteurism: Peter enjoys subway rush-hour female contact that results in arousal. D. Pedophilia: George can experience an orgasm by holding and feeling shoes. E. Fetishism: Henry masturbates into his wife's silk panties.

ANS: B, C, E Categories of paraphilia include voyeurism (observing unsuspecting people who are naked, dressing, or engaged in sexual activity), frotteurism (touching or rubbing against a nonconsenting person), fetishism (using nonliving objects in sexual ways), and pedophilia (recurrent sexual urges involving sexual activity with a prepubescent child). Exhibitionism is a paraphilia but involves the urge to show one's genitals to unsuspecting strangers.

A nurse attends an interdisciplinary team meeting on an inpatient unit. Which of the following individuals are typically included as members of the interdisciplinary treatment team in psychiatry? (Select all that apply.) A. Respiratory therapist and psychiatrist B. Occupational therapist and psychologist C. Recreational therapist and art therapist D. Social worker and hospital volunteer E. Mental health technician and chaplain

ANS: B, C, E The interdisciplinary treatment team in a psychiatric inpatient setting consists of a psychologist, occupational therapist, recreational therapist, art therapist, mental health technician, and chaplain. In addition, a psychiatrist, psychiatric nurse, psychiatric social worker, music therapist, psychodramatist, and dietician participate in the interdisciplinary treatment team.

A client is newly admitted to an inpatient psychiatric unit. Which assessment data are critical in determining an increased risk for suicide? A. Monitoring the client continually for 1 hour after admission B. Encouraging the client to discuss feelings C. Asking the client about any history of suicide attempts D. Removing hazardous materials from the environment

ANS: C A history of suicide attempts places a client at a higher risk for current suicide behaviors. Knowing this specific data will alert the nurse to the client's risk.

A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam? A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out senile dementia D. To rule out a personality disorder

ANS: C A mini-mental status exam should be performed to rule out senile dementia. The elderly are often misdiagnosed with senile dementia when depression is their actual diagnosis. Memory loss, confused thinking, or apathy symptomatic of dementia actually may be the result of depression.

A client diagnosed with major depressive disorder states, "Why should I keep trying to get a job? I mess up everything I do." Which correctly written nursing diagnosis best reflects the content and mood themes in this client's statement? A. Hopelessness R/T poor job performance B. Risk for impaired adjustment R/T inadequate social skills AEB isolation C. Altered role performance R/T the fear of failure AEB not seeking employment D. Chronic low self-esteem R/T major depressive disorder AEB self-hatred

ANS: C An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A risk for diagnosis does not contain AEB because there is only a potential for the problem, it doesn't as of yet exist. The client's statement indicates that role performance is altered due to the fact that fear of failure prevents seeking employment.

During family counseling a child states, "I just want to surf like other kids. Mom says it's okay, but Dad says I'm too young." The mother allows surfing when the father is absent. In the structural model of family therapy, what family interactional pattern should the nurse recognize? A. Multigenerational transmission B. Disengagement C. Mother-child subsystem D. Emotional cutoff

ANS: C In this situation, the mother and child have formed a subsystem in which they have aligned themselves against the father.

When questioned about bruises, a woman states, "It was an accident. My husband just had a bad day at work. He's being so gentle now and even brought me flowers. He's going to get a new job, so it won't happen again." This client is in which phase of the cycle of battering? A. Phase I: The tension-building phase B. Phase II: The acute battering incident phase C. Phase III: The honeymoon phase D. Phase IV: The resolution and reorganization phase

ANS: C The client is in the honeymoon phase of the cycle of battering. In this phase, the batterer becomes extremely loving, kind, and contrite. Promises are often made that the abuse will not happen again.

How should a nurse best describe the major maladaptive client response to panic disorder? A. Clients overuse medical care due to physical symptoms. B. Clients use illegal drugs to ease symptoms. C. Clients perceive having no control over life situations. D. Clients develop compulsions to deal with anxiety.

ANS: C The major maladaptive client response to panic disorder is the perception of having no control over life situations which leads to nonparticipation in decision making and doubts regarding role performance.

A female client on an inpatient unit enters the day area for visiting hours dressed in a see-through blouse and wearing no undergarments. Which intervention should be a nurse's first priority? A. Discuss with the client the inappropriateness of her attire. B. Avoid addressing her attention-seeking behavior. C. Lead the client back to her room and assist her to choose appropriate clothing. D. Restrict client to room until visiting hours are over.

ANS: C The most appropriate intervention by the nurse is to lead the client back to her room and assist her to choose appropriate clothing. The client could be exhibiting signs of exhibitionism which is characterized by urges to expose oneself to unsuspecting strangers.

A client diagnosed with antisocial personality disorder comes to a nurses' station at 11:00 p.m. requesting to phone a lawyer to discuss filing for a divorce. The unit rules state that no phone calls are permitted after 10:00 p.m. Which nursing reply is most appropriate? A. "Go ahead and use the phone. I know this pending divorce is stressful." B. "You know better than to break the rules. I'm surprised at you." C. "It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow." D. "The decision to divorce should not be considered until you have had a good night's sleep."

ANS: C The most appropriate response by the staff is to restate the unit rules in a calm, assertive manner. Because of the probability of manipulative behavior in this client population, it is imperative to maintain consistent application of rules.

An aging client diagnosed with chronic schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol) for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate? A. "Make sure you concentrate on taking slow, deep, cleansing breaths." B. "Watch your diet and try to engage in some regular physical activity." C. "Rise slowly when you change position from lying to sitting or sitting to standing." D. "Wear sunscreen and try to avoid midday sun exposure."

ANS: C The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, this side effect places the client at risk for developing orthostatic hypotension.

Upon admission for symptoms of alcohol withdrawal a client states, "I haven't eaten in 3 days." Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis? A. Knowledge deficit B. Fluid volume excess C. Imbalanced nutrition: less than body requirements D. Ineffective individual coping

ANS: C The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.

A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which personality disorder should a nurse associate with this assessment data? A. Compulsive personality disorder B. Schizotypal personality disorder C. Histrionic personality disorder D. Manic personality disorder

ANS: C The nurse should associate histrionic personality disorder with this assessment data. Individuals diagnosed with histrionic personality disorder tend to be self-dramatizing, attention seeking, overly gregarious, and seductive. They often use manipulation and exhibitionism as a means of gaining attention.

Which reaction to a compliment from another client should a nurse identify as a typical response from a client diagnosed with avoidant personality disorder? A. Interpreting the compliment as a secret code used to increase personal power B. Feeling the compliment was well deserved C. Being grateful for the compliment but fearing later rejection and humiliation D. Wondering what deep meaning and purpose are attached to the compliment

ANS: C The nurse should identify that a client diagnosed with avoidant personality disorder would be grateful for the comment but would fear later rejection and humiliation. Individuals with avoidant personality disorder are extremely sensitive to rejection and are often awkward and uncomfortable in social situations.

A client's altered body image is evidenced by claims of "feeling fat" even though the client is emaciated. Which is the appropriate outcome criterion for this client's problem? A. The client will consume adequate calories to sustain normal weight. B. The client will cease strenuous exercise programs. C. The client will perceive an ideal body weight and shape as normal. D. The client will not express a preoccupation with food.

ANS: C The nurse should identify that the appropriate outcome for this client is to perceive an ideal body weight and shape as normal. Additional goals include accepting self based on self-attributes instead of appearance and to realize that perfection is unrealistic.

A client who will be receiving electroconvulsive therapy (ECT) must provide informed consent. Which situation should cause a nurse to question the validity of the informed consent? A. The client is paranoid. B. The client is 87 years old. C. The client incorrectly reports his or her spouse's name, date, and time of day. D. The client relies on his or her spouse to interpret the information.

ANS: C The nurse should question the validity of informed consent when the client incorrectly reports the spouse's name, date, and time of day. This indicates that this client is disoriented and may not be competent to make informed choices.

A morbidly obese client is prescribed an anorexiant medication. The nurse should prepare to teach the client about which medication? A. Diazepam (Valium) B. Dexfenfluramine (Redux) C. Sibutramine (Meridia) D. Pemoline (Cylert)

ANS: C The nurse should teach the client that sibutramine (Meridia) is an anorexiant medication prescribed for morbidly obese clients. The mechanism of action in the control of appetite appears to occur by inhibiting the neutotransmitters serotonin and norepinephrine. Withdrawal from anorexiants can result in rebound weight gain, lethargy, and depression.

An angry client on an inpatient unit approaches a nurse stating, "Someone took my lunch! People need to respect others, and you need to do something about this now!" The nurse's response should be guided by which basic assumption of milieu therapy? A. Conflict should be avoided at all costs on inpatient psychiatric units. B. Conflict should be resolved by the nursing staff. C. Every interaction is an opportunity for therapeutic intervention. D. Conflict resolution should only be addressed during group therapy.

ANS: C The nurse's response should be guided by the basic assumption that every interaction is an opportunity for therapeutic intervention. The nurse can utilize milieu therapy to effect behavioral change and improve psychological health and functioning.

When planning care for clients diagnosed with personality disorders, what should be the anticipated treatment outcome? A. To stabilize pathology with the correct combination of medications B. To change the characteristics of the dysfunctional personality C. To reduce inflexibility of personality traits that interfere with functioning and relationships D. To decrease the prevalence of neurotransmitters at receptor sites

ANS: C The outcome of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. Personality disorders are often difficult and, in some cases, seem impossible to treat.

A client's younger daughter is ignoring curfew. The client states, "I'm afraid she will get pregnant." The nurse responds, "Hang in there. Don't you think she has a lot to learn about life?" This is an example of which communication block? A. Requesting an explanation B. Belittling the client C. Making stereotyped comments D. Probing

ANS: C This is an example of the nontherapeutic communication block of making stereotyped comments. Clichés and trite expressions are meaningless in a therapeutic nurse-client relationship.

A client with a history of insomnia has been taking chlordiazepoxide (Librium) 15 mg at night for the past year. The client currently reports getting to sleep. Which nursing diagnosis appropriately documents this problem? A. Ineffective coping R/T unresolved anxiety AEB substance abuse B. Anxiety R/T poor sleep AEB difficulty falling asleep C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep D. Risk for injury R/T addiction to Librium

ANS: C Tolerance is defined as the need for increasingly larger or more frequent doses of a substance in order to obtain the desired effects originally produced by a lower dose.

A client is in therapy with a nurse practitioner for the treatment of arachnophobia. The nurse practitioner decides to use the technique of "flooding." Which intervention best exemplifies this technique? A. Giving rewards for demonstrating a decrease in fear of spiders B. Encouraging the client to sit through the movie "Spiderman" C. Accompanying the client to a 1-hour visit to the local zoo's spider room D. Offering a computer program that progressively presents anxiety-producing spider scenarios

ANS: C Visiting the spider room would flood the client with the phobic stimuli of real spiders. This would continue until the stimulus no longer creates anxiety.

The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to assess and attempt to modify the negative thought patterns of these clients. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory

ANS: C When a nurse assesses and attempts to modify negative thought patterns related to depressive symptoms, the nurse is using a cognitive theory framework.

A nurse charts "Verbalizes understanding of the side effects of Prozac." This is an example of which category of focused charting? A. Data B. Problem C. Action D. Response

ANS: D "Verbalizes understanding of the side effects of Prozac." is an example of the response category of focused charting. The response is a description of the client's reaction to any part of medical or nursing care.

Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal? A. Antagonist therapy B. Deterrent therapy C. Codependency therapy D. Substitution therapy

ANS: D A CNS depressant such as Ativan is used during alcohol withdrawal as substitution therapy to prevent life-threatening symptoms that occur because of the rebound reaction of the central nervous system.

A client exhibits dependency on staff and peers and expresses fear of abandonment. Using Mahler's theory of object relations, which should the nurse expect to note in this client's childhood? A. Lack of fulfillment of basic needs by parental figures B. Absence of the client's maternal figure during symbiosis C. Difficulty establishing trust with the maternal figure D. Inconsistency by the maternal figure during individuation

ANS: D During phase 3 (5 to 36 months) of Margaret Mahler's individuation theory, there should be a strengthening of the ego and an acceptance of "self" with independent ego boundaries. Inconsistency by the maternal figure during individuation may in later years result in feelings of helplessness when the client is alone because of exaggerated fears of being unable to care for self.

A kindergarten rule states that if unacceptable behavior occurs, a child's personalized fish will be moved to the sea grass. Children who behave keep their fish out of the sea grass. The school nurse should identify this intervention as based on which principle of behavior therapy? A. Classical conditioning B. Conditioned response C. Positive reinforcement D. Negative reinforcement

ANS: D Negative reinforcement is increasing the probability that behavior (appropriate classroom behavior) will recur by removal of an undesirable reinforcing stimulus (personalized fish in sea grass).

The treatment team is making a discharge decision regarding a previously suicidal client. Which client assessment information should a nurse recognize as contributing to the team's decision? A. No previous admissions for major depressive disorder B. Vital signs stable; no psychosis noted C. Able to comply with medication regimen; able to problem-solve life issues D. Able to participate in a plan for safety; family agrees to constant observation

ANS: D Participation in a plan of safety and constant family observation will decrease the risk for self-harm. All other answer choices are not directly focused on suicide prevention and safety.

A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client? A. The client is placed in seclusion. B. The client is placed in a geriatric chair with tray. C. The client is placed in soft Posey restraints. D. The client is monitored by an ankle bracelet.

ANS: D The least restrictive alternative for this client would be monitoring by an ankle bracelet. The client does not pose a direct dangerous threat to self or others, so neither physical restraints nor seclusion would be justified.

In the role of milieu manager, which activity should the nurse prioritize? A. Setting the schedule for the daily unit activities B. Evaluating clients for medication effectiveness C. Conducting therapeutic group sessions D. Searching newly admitted clients for hazardous objects

ANS: D The milieu manager should search newly admitted clients for hazardous objects. Safety of the client and others is the priority. Nurses are responsible for ensuring that the client's safety and physiological needs are met within the milieu.

Which nursing intervention would be most appropriate when caring for an acutely agitated client diagnosed with paranoid schizophrenia? A. Provide neon lights and soft music. B. Maintain continual eye contact throughout the interview. C. Use therapeutic touch to increase trust and rapport. D. Provide personal space to respect the client's boundaries.

ANS: D The most appropriate nursing intervention is to provide personal space to respect the client's boundaries. Providing personal space may serve to reduce anxiety and thus reduce the client's risk for violence.

A client on an inpatient unit angrily states to a nurse, "Peter is not cleaning up after himself in the community bathroom. You need to address this problem." Which is the appropriate nursing response? A. "I'll talk to Peter and present your concerns." B. "Why are you overreacting to this issue?" C. "You should bring this to the attention of your treatment team." D. "I can see that you are angry. Let's discuss ways to approach Peter with your concerns."

ANS: D The most appropriate nursing response involves restating the client's feeling and developing a plan with the client to solve the problem. According to Skinner, every interaction in the therapeutic milieu is an opportunity for therapeutic intervention to improve communication and relationship-development skills.

A client who frequently exhibits angry outbursts is diagnosed with antisocial personality disorder. Which appropriate feedback should a nurse provide when this client experiences an angry outburst? A. "Why do you continue to alienate your peers by your angry outbursts?" B. "You accomplish nothing when you lose your temper like that." C. "Showing your anger in that manner is very childish and insensitive." D. "During group, you raised your voice, yelled at a peer, left, and slammed the door."

ANS: D The nurse is providing appropriate feedback when stating, "During group, you raised your voice, yelled at a peer, left, and slammed the door." Giving appropriate feedback involves helping the client consider a modification of behavior. Feedback should give information to the client about how he or she is perceived by others. Feedback should not be evaluative in nature or be used to give advice.

A client diagnosed with seasonal affective disorder (SAD) states, "I've been feeling 'down' for 3 months. Will I ever feel like myself again?" Which reply by the nurse will best assess this client's symptoms. A. "Have you been diagnosed with any physical disorder within the last 3 months?" B. "Have you experienced any traumatic events that triggered this mood change?" C. "People who have seasonal mood changes often feel better when spring comes." D. "Help me understand what you mean when you say, 'feeling down'?"

ANS: D The nurse is using a clarifying statement in order to gather more details related to this client's mood. The diagnosis of SAD is not associated with a traumatic event.

A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

ANS: D The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-IV-TR, these symptoms would rule out the diagnosis of major depressive disorder.

A client is diagnosed with dysthymic disorder. Which should a nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life

ANS: D The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymic disorder. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological.

Which client statement indicates a knowledge deficit related to substance abuse? A. "Although it's legal, alcohol is one of the most widely abused drugs in our society." B. "Tolerance to heroin develops quickly." C. "Flashbacks from LSD use may reoccur spontaneously." D. "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."

ANS: D The nurse should determine that the client has a knowledge deficit related to substance abuse when the client compares marijuana to smoking cigarettes and claims it to be harmless. Cannabis is the second most widely abused drug in the United States.

A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client's problem? A. Distract the client with other activities whenever ritual behaviors begin. B. Report the behavior to the psychiatrist to obtain an order for medication dosage increase. C. Lock the room to discourage ritualistic behavior. D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

ANS: D The nurse should discuss with the client the anxiety-provoking triggers that precipitate the ritualistic behavior. If the client is going to be able to avoid the anxiety, he or she must first learn to recognize precipitating factors. Attempting to distract the client, seeking medication increase, and locking the client's room are not appropriate interventions because they do not help the client recognize anxiety triggers.

A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify? A. Sublimation B. Dissociation C. Rationalization D. Intellectualization

ANS: D The nurse should identify that the client is using the defense mechanism of intellectualization when discussing the rituals of obsessive-compulsive disorder in detail while avoiding discussion of feelings. Intellectualization is an attempt to avoid expressing emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis.

A cab driver, stuck in traffic, suddenly is lightheaded, tremulous, diaphoretic, and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority? A. Generalized anxiety disorder and a nursing diagnosis of fear B. Altered sensory perception and a nursing diagnosis of panic disorder C. Pain disorder and a nursing diagnosis of altered role performance D. Panic disorder and a nursing diagnosis of anxiety

ANS: D The nurse should suspect that the client has exhibited signs/symptoms of a panic disorder. The priority nursing diagnosis should be anxiety. Panic disorder is characterized by recurrent, sudden onset panic attacks in which the person feels intense fear, apprehension, or terror.

A woman describes a history of physical and emotional abuse in intimate relationships. Which additional factor should a nurse suspect? A. The woman may be exhibiting a controlled response pattern. B. The woman may have a history of childhood neglect. C. The woman may be exhibiting codependent characteristics. D. The woman might be a victim of incest.

ANS: D The nurse should suspect that this client might be a victim of incest. Women in abusive relationships often grew up in abusive homes.

In planning care for a suicidal client, which correctly written outcome should be a nurse's first priority? A. The client will not physically harm self. B. The client will express hope for the future by day 3. C. The client will establish a trusting relationship with the nurse. D. The client will remain safe during the hospital stay.

ANS: D The nurse's priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurse's priority. The "A" answer choice is incorrectly written. Correctly written outcomes must be client focused, measurable, realistic, and contain a time frame. Without a time frame, an outcome cannot be correctly evaluated.

A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, "Why doesn't she just leave him?" Which is the nursing supervisor's most appropriate reply? A. "These clients don't know life any other way, and change is not an option until they have improved insight." B. "These clients have limited KEY: Cognitive skills and few vocational abilities to be able to make it on their own." C. "These clients often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation." D. "These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness."

ANS: D The nursing supervisor is accurate when stating that clients in severely abusive relationships are paralyzed into inaction by a combination of physical threats and a sense of powerlessness. Women often choose to stay with an abusive partner for some of the following reasons: for the children, for financial reasons, fear of retaliation, lack of a support network, religious reasons, and/or hopelessness.

A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects the underlying etiology of this disorder? A. "Skaters need to be thin to improve their daily performance." B. "All the skaters on the team are following an approved 1,200-calorie diet." C. "When I lose skating competitions, I also lose my appetite." D. "I am angry at my mother. I can only get her approval when I win competitions."

ANS: D This client statement reflects the underlying etiology of anorexia nervosa. The client is expressing feelings about family dynamics that may have influenced the development of this disorder. Families who are overprotective and perfectionistic can contribute to a family member's development of anorexia nervosa.

A suicidal client says to a nurse, "There's nothing to live for anymore." Which is the most appropriate nursing reply? A. "Why don't you consider doing volunteer work in a homeless shelter." B. "Let's discuss the negative aspects of your life." C. "Things will look better in the morning." D. "It sounds like you are feeling pretty hopeless."

ANS: D This statement verbalizes the client's implied feelings and allows him to validate and explore them.

A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish? A. The client will identify one person to turn to for support. B. The client will give up all old drinking buddies. C. The client will be able to verbalize the effects of alcohol on the body. D. The client will correlate life problems with alcohol use.

ANS: D To promote the recovery process the nurse should expect that the client would initially correlate life problems with alcohol use. Acceptance of the problem is the first step of the recovery process.

During family counseling, a husband tells his wife to spend more time with the family, and she responds by stating, "Okay, I'll turn in my resignation tomorrow." The husband replies, "I knew it! You've always been a quitter!" How should the nurse interpret the husband's statement? A. The husband is expressing an emotional cutoff. B. The husband is expressing double-bind communication. C. The husband is expressing indirect messages. D. The husband is expressing avoidance behaviors.

ANS: B Double-bind communication sets up no-win situations. The husband has created a situation in which no matter what the wife does, she is wrong.

According to behavioral theory, the treatment of phobic symptoms should involve which action? A. The manipulation of the environment B. The use of desensitization C. The use of family therapy D. The uncovering of past events

ANS: B Systematic desensitization is a technique for assisting individuals to overcome their fear of a phobic stimulus. It is "systematic" in that there is a hierarchy of anxiety-producing events through which the individual progresses during therapy.

A client diagnosed with schizophrenia tells a nurse, "The 'Shopatouliens' took my shoes out of my room last night." Which is an appropriate charting entry to describe this client's statement? A. "The client is experiencing command hallucinations." B. "The client is expressing a neologism." C. "The client is experiencing a paranoid delusion." D. "The client is verbalizing a word salad."

ANS: B The nurse should describe the client's statement as experiencing a neologism. A neologism is when a client invents a new word that is meaningless to others but may have symbolic meaning to the client. Word salad refers to a group of words that are put together randomly.

A stockbroker commits suicide after being convicted of insider trading. Which information should a nurse share with the grieving family? A. "Keep in mind that your grieving will only last for 1 year." B. "To deal with your grief, try using coping strategies that have worked for you in the past." C. "You need to write a letter to the brokerage firm to express your anger with them." D. "It would be best if you avoid discussing the suicide."

ANS: B The nurse should discuss coping strategies that have been successful in times of stress in the past, and work to reestablish these within the family.

A client is admitted with a diagnosis of depression NOS (not otherwise specified). Which client statement would describe a somatic symptom that can occur with this diagnosis? A. "I am extremely sad, but I don't know why." B. "Sometimes I just don't want to eat because I ache all over." C. "I feel like I can't ever make the right decision." D. "I can't seem to leave the house without someone with me."

ANS: B When a client diagnosed with depression expresses physical complaints, the client is experiencing somatic symptoms. Somatic symptoms occur with depression because of a general slowdown of the entire body reflected in sluggish digestion, constipation, impotence, anorexia, difficulty falling asleep, and a wide variety of other symptoms.

A 2-year-old engages in frequent temper tantrums that usually result in the parents giving in to demands. During family therapy, how should a nurse counsel the parents? A. "You are shaping your child's behavior." B. "Your child has modeled your behavior." C. "You are positively reinforcing your child's behavior." D. "You are negatively reinforcing your child's behavior."

ANS: C

A 75-year-old client diagnosed with a long history of depression is currently on doxepin (Sinequan) 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count

ANS: C A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension.

A nurse is working with a client diagnosed with pedophilia. Which client outcome is appropriate for the nurse to expect during the first week of hospitalization? A. The client will verbalize an understanding of the importance of follow-up care. B. The client will implement several relapse-prevention strategies. C. The client will identify triggers that lead to inappropriate behaviors. D. The client will attend aversion therapy groups.

ANS: C During the first week of hospitalization, identifying triggers that lead to inappropriate behaviors is an appropriate outcome for a client diagnosed with pedophilia. Pedophilia involves intense sexual urges, behaviors, or fantasies involving sexual activity with a prepubescent child.

Which task should the nurse recognize as appropriate to stage IV of the family life cycle? A. Making adjustments within the marital system to meet the responsibilities of parenthood B. Establishing a new identity as a couple by realigning relationships with extended family C. Redefining the level of dependence so that adolescents are provided with greater autonomy D. Reestablishing the bond of the dyadic marital relationship

ANS: C Stage IV of the family life cycle is described as the "The Family with Adolescents." The task of this stage is to redefine the level of dependence so that adolescents are provided with greater autonomy while parents remain responsive to teenagers' dependency needs.

Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)? A. CIWA scale B. GGT C. MMSE D. CAPS scale

ANS: C The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdrawal from substances such as alcohol. The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and symptoms of PTSD. The GGT test is used to assess gamma-glutamyl transferase levels which may be an indication of alcoholism.

A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate? A. Provide objective evidence, that violence is unwarranted. B. Initially restrain the client to maintain safety. C. Use clear, calm statements and a confident physical stance. D. Empathize with the client's paranoid perceptions.

ANS: C The most appropriate nursing intervention is to use clear, calm statements and to assume a confident physical stance. A calm attitude avoids escalating the aggressive behavior and provides the client with a feeling of safety and security. It may also be beneficial to have sufficient staff on hand to present a show of strength.

A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, "The beatings have been getting worse, and I'm afraid that next time he might kill me." Which is the appropriate nursing reply? A. "Leopards don't change their spots, and neither will he." B. "There are things you can do to prevent him from losing control." C. "Let's talk about your options so that you don't have to go home." D. "Why don't we call the police so that they can confront your husband with his behavior?"

ANS: C The most appropriate reply by the nurse is to talk with the client about options so that the client does not have to return to the abusive environment. It is essential that clients make decisions independently without the nurse being the "rescuer." Imposing judgments and giving advice is nontherapeutic.

A brother calls to speak to his sister who has been admitted to the psychiatric unit. The nurse connects him to the community phone and the sister is summoned. Later the nurse realizes that the brother was not on the client's approved call list. What law has the nurse broken? A. The National Alliance for the Mentally Ill Act B. The Tarasoff Ruling C. The Health Insurance Portability and Accountability Act D. The Good Samaritan Law

ANS: C The nurse has violated the Health Insurance Portability and Accountability Act (HIPAA) by revealing that the client had been admitted to the psychiatric unit. The nurse should not have provided any information without proper consent from the client.

Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which information related to a client's home environment should a nurse associate with the development of this disorder? A. The home environment maintains loose personal boundaries. B. The home environment places an overemphasis on food. C. The home environment is overprotective and demands perfection. D. The home environment condones corporal punishment.

ANS: C The nurse should assess that a home environment that is overprotective and demands perfection may be a major influence in the development of anorexia nervosa. In adolescence, distorted eating patterns may represent a rebellion against controlling and demanding parents.

A client is newly committed to an inpatient psychiatric unit. Which nursing intervention best lowers this client's risk for suicide? A. Encouraging participation in the milieu to promote hope B. Developing a strong personal relationship with the client C. Observing the client at intervals determined by assessed data D. Encouraging and redirecting the client to concentrate on happier times

ANS: C The nurse should observe the actively suicidal client continuously for the first hour after admission. After a full assessment, the treatment team will determine the observation status of the client. Observation of the client allows the nurse to interrupt any observed suicidal behaviors.

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse? A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader

ANS: C The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients in communicating needs and maintaining connectedness.

A client who has been raped is crying, pacing, and cursing her attacker in an emergency department. Which behavioral defense should a nurse recognize? A. Controlled response pattern B. Compounded rape reaction C. Expressed response pattern D. Silent rape reaction

ANS: C The nurse should recognize that this client is exhibiting an expressed response pattern. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension. In the controlled response pattern, the client's feelings are masked or hidden, and a calm, composed, or subdued affect is seen.

Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder? A. The client experiences unwanted, intrusive, and persistent thoughts. B. The client experiences unwanted, repetitive behavior patterns. C. The client experiences inflexibility and lack of spontaneity when dealing with others. D. The client experiences obsessive thoughts that are externally imposed.

ANS: C The nurse should suspect a diagnosis of obsessive-compulsive personality disorder when a client experiences inflexibility and lack of spontaneity. Individuals diagnosed with this disorder are very serious, formal, and have difficulty expressing emotions. They are perfectionistic and preoccupied with rules.

Which statement regarding nursing interventions should a nurse identify as accurate? A. Nursing interventions are independent from the treatment team's goals. B. Nursing interventions are solely directed by written physician orders. C. Nursing interventions occur independently but in concert with overall treatment team goals. D. Nursing interventions are standardized by policies and procedures.

ANS: C The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the client's care.

Which situation reflects the ethical principle of veracity? A. A nurse provides a client with outpatient resources to benefit recovery. B. A nurse refuses to give information to a physician who is not responsible for the client's care. C. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room. D. A nurse treats all of the clients equally regardless of illness severity.

ANS: C The nurse who tricks a client into seclusion has violated the ethical principle of veracity. The principle of veracity refers to one's duty to always be truthful and not intentionally deceive or mislead clients.

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time? A. Obtaining an order for locked seclusion until client is no longer suicidal B. Conducting 15-minute checks to ensure safety C. Placing the client on one-to-one observation while monitoring suicidal ideations D. Encouraging client to express feelings related to suicide

ANS: C The nurse's priority intervention when a client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideation.

A college student is unable to take a final examination due to severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should a campus nurse assign for this client? A. Noncompliance R/T test taking B. Ineffective role performance R/T helplessness C. Altered coping R/T anxiety D. Powerlessness R/T fear

ANS: C The priority nursing diagnosis for this client is altered coping R/T anxiety. The nurse should assist in implementing interventions that should improve the client's healthy coping skills and reduce anxiety.

Sertraline (Zoloft) has been prescribed for a client complaining of poor appetite, fatigue, and anhedonia. Which consideration should the nurse recognize as influencing this prescriptive choice? A. Zoloft is less expensive for the client. B. Zoloft is extremely sedating and will help with sleep disturbances. C. Zoloft has less adverse side effects than other antidepressants. D. Zoloft begins to improve depressive symptoms quickly.

ANS: C Zoloft is a selective serotonin reuptake inhibitor (SSRI) that has a relatively benign side effect profile as compared with other antidepressants.

A couple has been married for 20 years. They argue constantly, belittle feelings, and continuously contradict each other. During a therapy session, the nurse documents "Marital schism." What does the nurse mean by this documentation? A. The couple has a compatible marriage relationship. B. The husband has a dominant relationship over the wife. C. The couple has an enmeshed relationship. D. The couple has an incompatible marriage relationship.

ANS: D A marital schism is a state of chronic disequilibrium and discord. This describes this couple's marriage.

During her aunt's wake, before a mother can stop her 4-year-old child, the child runs up to the casket. An appointment is made with a nurse practitioner when the child starts twisting and pulling out hair. Which nursing diagnosis should the nurse practitioner assign to this child? A. Complicated grieving B. Altered family processes C. Ineffective coping D. Body image disturbance

ANS: C Ineffective coping is defined as an inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or the inability to use available resources. This child is coping with the anxiety generated by viewing her deceased aunt by pulling out hair. If this behavior continues, a diagnosis of the impulse control disorder, trichotillomania, may be assigned.

A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first? A. Communicate therapeutically. B. Observe the client. C. Provide a hazard-free environment. D. Assess suicide risk.

ANS: D Assessment is the first step of the nursing process to gain needed information to determine further appropriate interventions.

A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)

ANS: D Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.

Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. "It's just a matter of time and I will be well." B. "If I ignore these feelings, they will go away." C. "I can fight these feelings and overcome this disorder." D. "I deserve to feel this way."

ANS: D Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder. Depressive symptoms are often described as anger turned inward.

A nursing instructor is teaching about suicide. Which student statement indicates that learning has occurred? A. "Suicidal threats and gestures should be considered manipulative and/or attention-seeking." B. "Suicide is the act of a psychotic person." C. "All suicidal individuals are mentally ill." D. "50% to 80% of all people who kill themselves have a history of a previous attempt."

ANS: D It is a fact that between 50% and 80% of all people who kill themselves have a history of a previous attempt. All other answer choices are myths about suicide.

A 20-year-old client and a 60-year-old client have had drunk driving accidents and are both experiencing extreme anxiety. From a psychosocial theory perspective, which of these clients would be predisposed to the diagnosis of adjustment disorder? A. The 60-year-old because of memory deficits B. The 60-year-old because of decreased cognitive processing ability C. The 20-year-old because of limited cognitive experiences D. The 20-year-old because of lack of developmental maturity

ANS: D Research indicates that there is a predisposition to the diagnosis of adjustment disorder when there is limited developmental maturity. By comparison, the 20-year-old does not have the developmental maturity, life experiences, and coping mechanisms that the 60-year-old might possess.

What is the purpose of a nurse providing appropriate feedback? A. To give the client good advice B. To advise the client on appropriate behaviors C. To evaluate the client's behavior D. To give the client critical information

ANS: D The purpose of providing appropriate feedback is to give the client critical information. Feedback should not be used to give advice or evaluate behaviors.

A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. The treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice? A. This therapy will increase the client's motivation to gain weight. B. This therapy will reward the client for perfectionist achievements. C. This therapy will provide the client with control over behavioral choices. D. This therapy will protect the client from parental overindulgence.

A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. The treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice? A. This therapy will increase the client's motivation to gain weight. B. This therapy will reward the client for perfectionist achievements. C. This therapy will provide the client with control over behavioral choices. D. This therapy will protect the client from parental overindulgence.

How would a nurse differentiate a client diagnosed with obsessive-compulsive disorder (OCD) from a client diagnosed with obsessive-compulsive personality disorder? A. Clients diagnosed with OCD experience both obsessions and compulsions, and clients diagnosed with obsessive-compulsive personality disorder do not. B. Clients diagnosed with obsessive-compulsive personality disorder experience both obsessions and compulsions, and clients diagnosed with OCD do not. C. Clients diagnosed with obsessive-compulsive personality disorder experience only obsessions, and clients diagnosed with OCD experience only compulsions. D. Clients diagnosed with OCD experience only obsessions, and clients diagnosed with obsessive-compulsive personality disorder experience only compulsions.

ANS: A A client diagnosed with OCD experiences both obsessions and compulsions. Clients diagnosed with obsessive-compulsive personality disorder exhibit a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control.

A client is admitted to the psychiatric unit with a diagnosis of major depression. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this client's plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation

ANS: A A client diagnosed with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate.

Which nursing statement reflects a common characteristic of a client diagnosed with paranoid personality disorder? A. "This client consistently criticizes care and has difficulty getting along with others." B. "This client is shy and fades into the background." C. "This client expects special treatment and setting limits will be necessary." D. "This client is expressive during group and is very pleased with self."

ANS: A A client diagnosed with paranoid personality disorder has a pervasive distrust and suspiciousness of others. Anticipating humiliation and betrayal, the paranoid individual characteristically learns to attack first.

A client diagnosed with major depressive disorder was raised in an excessively religiously based household. Which nursing intervention would be most appropriate to address this client's underlying problem? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system in order to improve coping skills.

ANS: A A client raised in an excessively religiously based household maybe at risk for experiencing guilt to the point of accepting liability in situations for which one is not responsible. The client may view himself or herself as evil and deserving of punishment leading to depression. Assisting the client to bring these feelings into awareness allows the client to realistically appraise distorted responsibility and dysfunctional guilt.

A nurse should recognize which intervention as most appropriate within a behavioral therapy program? A. A child is given a Popsicle for staying dry and clean. B. A child is put in time-out after soiling his or her undergarments. C. A child is allowed to remain in soiled undergarments. D. A child is taught the advantages of staying dry and clean.

ANS: A A stimuli that follows a behavior or response is called a reinforcing stimulus or reinforcer. The reward of a Popsicle is a reinforcer for the child staying dry and clean. This is an example of operant conditioning, a form of behavioral therapy.

A nurse reviews the laboratory data of a client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL

ANS: A According to the DSM-IV-TR, symptoms of major depressive disorder cannot be due to the direct physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of major depressive disorder may be ruled out if the client's laboratory results indicate a high TSH level which results from a low thyroid function or hypothyroidism. In hypothyroidism, metabolic processes are slowed leading to depressive symptoms.

When a client on an acute care psychiatric unit demonstrates behaviors and verbalizations indicating a lack of guilt feelings, which nursing intervention would help the client to meet desired outcomes? A. Provide external limits on client behavior. B. Foster discussions of rationales for behavioral change. C. Implement interventions consistently by only one staff member. D. Encourage the client to involve self in care.

ANS: A Because the client, due to a lack of guilt, cannot or will not impose personal limits on maladaptive behaviors, these limits must be delineated and enforced by staff.

A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the most appropriate reply by the nurse? A. "This medication will help you maintain your abstinence." B. "This medication will cause uncomfortable symptoms if you combine it with alcohol." C. "This medication will decrease the effect alcohol has on your body." D. "This medication will lower your risk of experiencing a complicated withdrawal."

ANS: A Campral has been approved by the U.S. Food and Drug Administration (FDA) for the maintenance of abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation.

Which characteristics should a nurse recognize as being exhibited by individuals diagnosed with any personality disorders? A. These clients accept and are comfortable with their altered behaviors. B. These clients understand that their altered behaviors result from anxiety. C. These clients seek treatment to avoid interpersonal discomfort. D. These clients avoid relationships due to past negative experiences.

ANS: A Clients who are diagnosed with personality disorders accept and are comfortable with their altered behaviors. Personalities that develop in a disordered pattern remain somewhat unstable and unpredictable throughout the lifetime.

A nurse is caring for a client who has threatened to commit suicide by hanging. The client states, "I'm going to use a knotted shower curtain when no one is around." Which information would determine the nurse's plan of care for this client? A. The more specific the plan is, the more likely the client will attempt suicide. B. Clients who talk about suicide never actually commit it. C. Clients who threaten suicide should be observed every 15 minutes. D. After a brief assessment, the nurse should avoid the topic of suicide.

ANS: A Clients who have specific plans are at greater risk for suicide.

A third-grader feigns illness in order to avoid doing homework. The teacher recommends an educational program that uses a token economy. How should a school nurse explain a token economy to this child's parent? A. "Your child will receive green tokens for completing homework that can be cashed in for desired rewards." B. "Your child will receive red tokens when homework is incomplete and this will result in school suspension." C. "Your child will receive a time out for each homework assignment not completed." D. "Your child, with your assistance, will envision receiving rewards for completed homework."

ANS: A In a token economy, tokens are a form of contingency contracting in that tokens immediately reinforce appropriate behavior (completed homework) and are exchanged later for a desired reward.

A mother states, "You are old enough to clean your own bedroom." Later inspection finds the floor clear, but with everything stacked in a chair. The mother praises the child for clearing the floor. This is consistent with which technique of behavior modification? A. Shaping B. Extinction C. Stimulus generalization D. Reciprocal inhibition

ANS: A In shaping, behavior is molded in a desired direction by reinforcing each small step toward the desired behavior. The child is praised for clearing the floor, the first step toward cleaning the room.

A nursing instructor is teaching about the correlation between pathological gambling and abnormalities in the neurotransmitter system. What statement by the nursing student indicates that learning has occurred? A. "Pathological gamblers present with decreased serotonin, increased norepinephrine, and increased dopamine." B. "Pathological gamblers present with increased serotonin, increased norepinephrine, and increased dopamine." C. "Pathological gamblers present with decreased serotonin, decreased norepinephrine, and decreased dopamine." D. "Pathological gamblers present with increased serotonin, decreased norepinephrine, and decreased dopamine."

ANS: A Serotonergic function is linked to behavioral initiation, inhibition, and aggression. Noradrenergic function mediates arousal and detects novel and aversive stimuli. Dopaminergic function is associated with reward and reinforcement mechanisms. Thus, pathological gamblers present with decreased serotonin, increased norepinephrine, and increased dopamine.

A clinic nurse is caring for a 40-year-old client who lives with his parents. The client's mother continues to do the client's laundry and provides spending money. Based on this situation, which family dynamic does the nurse recognize? A. Taking over B. Communicating indirectly C. Belittling feelings D. Making assumptions

ANS: A Taking over occurs when a family member fails to allow another member to develop a sense of responsibility and self-worth. By doing the client's laundry and managing finances, the mother is fostering the client's dependence.

A 15-year-old who is angry about not being chosen as the basketball team's captain, spray paints obscene words on the newly chosen captain's car. What information would cause a school nurse to consider a diagnosis of intermittent explosive disorder? A. The destruction of property is grossly out of proportion to the precipitating factor. B. The destruction of property is not a pattern of failure to resist aggressive impulses. C. The teenager has a diagnosis of conduct disorder. D. The teenager has previously been diagnosed with Tourette's syndrome.

ANS: A The DSM-IV-TR criteria for the diagnosis of intermittent explosive disorder state that several discrete episodes of destruction of property must occur, and the aggressive episode can not be better accounted for by another mental disorder such as conduct disorder or Tourette's syndrome. The degree of aggressiveness must be grossly out of proportion to the precipitating factor.

A nursing diagnosis of ineffective coping R/T feelings of loneliness AEB bingeing then purging when alone, is assigned to a client diagnosed with bulimia nervosa. Which is an appropriate outcome related to this nursing diagnosis? A. The client will identify two alternative methods of dealing with isolation by day 3. B. The client will appropriately express angry feelings about lack of control by week 2. C. The client will verbalize two positive self attributes by day 3. D. The client will list five ways that the body reacts to bingeing and purging.

ANS: A The ability to identify alternative methods of dealing with isolation will provide the client with effective coping strategies to use instead of bingeing and purging.

A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to a nurse that the student is handling this situation in a healthy manner? A. "I know that it was not my fault." B. "My boyfriend has trouble controlling his sexual urges." C. "If I don't put myself in a dating situation, I won't be at risk." D. "Next time I will think twice about wearing a sexy dress."

ANS: A The client who realizes that sexual assault was not her fault is handling the situation in a healthy manner. The nurse should provide nonjudgmental listening and communicate statements that instill trust and validate self-worth.

An instructor is teaching about differentiated parent and adult child relationships. Students are instructed to give an example of a well-differentiated parent and adult child relationship. Which student example meets the instructor requirement? A. An adult child considers, but is not governed by, the advice of his or her parents. B. An adult child appears to listen, but ignores, the advice of his or her parents. C. An adult child respects and is governed by the wishes of his or her parents. D. An adult child never requests advice or feedback from his or her parents.

ANS: A The correct student example of a well-differentiated parent and adult child relationship is when an adult child considers, but is not governed by, the advice of his or her parent. The adult child should be differentiated enough not to be threatened by parental advice and should be able to consider the parental advice without feeling the advice must be followed.

A client has a history of excessive fear of water. What is the term that a nurse should use to describe this specific phobia, and under what subtype is this phobia identified? A. Aquaphobia, a natural environment type of phobia B. Aquaphobia, a situational type of phobia C. Acrophobia, a natural environment type of phobia D. Acrophobia, a situational type of phobia

ANS: A The nurse should determine that an excessive fear of water is identified as aquaphobia which is a natural environment type of phobia. Natural environment-type phobias are fears about objects or situations that occur in the natural environment such as a fear of heights or storms.

Family members of a client ask a nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing reply? A. "Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone." B. "Clients diagnosed with schizoid personality disorder exhibit odd, bizarre, and eccentric behavior, while clients diagnosed with avoidant personality disorder do not." C. "Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant." D. "Clients diagnosed with schizoid personality disorder have a history of psychotic thought processes, while clients diagnosed with avoidant personality disorder remain based in reality."

ANS: A The nurse should educate the family that clients diagnosed with avoidant personality disorder desire intimacy but fear it, while clients diagnosed with schizoid personality disorder prefer to be alone. Avoidant personality disorder is characterized by an extreme sensitivity to rejection which leads to social isolation. Schizoid personality disorder is characterized by a profound deficit in the ability to form personal relationships.

If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect? A. White blood cell count B. Liver function studies C. Creatinine clearance D. Blood urea nitrogen

ANS: A The nurse should establish a baseline white blood cell count to evaluate a potentially life-threatening side effect if clozapine (Clozaril) is being considering as a treatment option. Clozapine can have a serious side effect of agranulocytosis in which a potentially fatal drop in white blood cells can occur.

After taking chlorpromazine (Thorazine) for 1 month, a client presents to an emergency department (ED) with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5C). The nurse expects the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing Thorazine and administering dantrolene (Dantrium) B. Neuroleptic malignant syndrome and treat by increasing Thorazine dosage and administering an antianxiety medication C. Dystonia and treat by administering trihexyphenidyl (Artane) D. Dystonia and treat by administering bromocriptine (Parlodel)

ANS: A The nurse should expect that an ED physician would diagnose the client with neuroleptic malignant syndrome and treat the client by discontinuing chlorpromazine (Thorazine) and administering dantrolene (Dantrium). Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability. The use of typical antipsychotics is largely being replaced by atypical antipsychotics due to fewer side effects and lower risks.

A newly married woman comes to a gynecology clinic reporting anorexia, insomnia, and extreme dyspareunia that have affected her intimate relationship. What initial intervention should the nurse expect a physician to implement? A. A thorough physical to include gynecological examination B. Referral to a sex therapist C. Assessment of sexual history and previous satisfaction with sexual relationships D. Referral to the recreational therapist for relaxation therapy

ANS: A The nurse should expect the physician to implement a thorough physical to include a gynecological examination to assess for any physiological causes of the client's symptoms. Dyspareunia is recurrent or persistent genital pain associated with sexual intercourse.

A 16-year-old-client diagnosed with paranoid schizophrenia experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing reply? A. "Your child has a chemical imbalance of the brain which leads to altered thoughts." B. "Your child's hallucinations are caused by medication interactions." C. "Your child has too little serotonin in the brain causing delusions and hallucinations." D. "Your child's abnormal hormonal changes have precipitated auditory hallucinations."

ANS: A The nurse should explain that a chemical imbalance of the brain leads to altered thought processes. Hallucinations, or false sensory perceptions, may occur in all five senses. The client who hears voices is experiencing an auditory hallucination.

A newly admitted client asks, "Why do we need a unit schedule? I'm not going to these groups. I'm here to get some rest." Which is the most appropriate nursing reply? A. "Group therapy provides the opportunity to learn and practice new coping skills." B. "Group therapy is mandatory. All clients must attend." C. "Group therapy is optional. You can go if you find the topic helpful and interesting." D. "Group therapy is an economical way of providing therapy to many clients concurrently."

ANS: A The nurse should explain to the client that the purpose of group therapy is to learn and practice new coping skills. A basic assumption of milieu therapy is that every interaction, including group therapy, is an opportunity for therapeutic intervention.

In the course of an assessment interview, a female client reveals a history of bisexual orientation. Which action should the nurse initially implement when working with this client? A. Self-assess personal attitudes toward homosexuality. B. Review client's possible childhood sexual abuse history. C. Encourage discussion of aversion to heterosexual relationships. D. Explore client's family history of homosexuality.

ANS: A The nurse should initially self-assess personal attitudes toward homosexuality. The nurse must be able to recognize the potential for negative feelings compromising client care. Unconditional acceptance of each individual is an essential component of compassionate nursing.

A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola

ANS: A The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread."

A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order? A. History of alcohol dependence B. History of personality disorder C. History of schizophrenia D. History of hypertension

ANS: A The nurse should question a prescription of alprazolam (Xanax) for acute anxiety if the client has a history of alcohol dependence. Alprazolam is a benzodiazepine used in the treatment of anxiety and has an increased risk for physiological dependence and tolerance. A client with a history of substance abuse may be more likely to abuse other addictive substances and/or combine this drug with alcohol.

Which assessment data should a school nurse recognize as signs of physical neglect? A. The child is often absent from school and seems apathetic and tired. B. The child is very insecure and has poor self-esteem. C. The child has multiple bruises on various body parts. D. The child has sophisticated knowledge of sexual behaviors.

ANS: A The nurse should recognize that a child who is often absent from school and seems apathetic and tired might be a victim of neglect. Other indicators of neglect are stealing food or money, lacking medical or dental care, being consistently dirty, lacking sufficient clothing, or stating that there is no one home to provide care.

A client is diagnosed with sexual aversion disorder. Which symptom of this disorder should the nurse correctly pair with an appropriate therapeutic intervention? A. Avoidance of all genital sexual contact treated by systematic desensitization B. Avoidance of all genital sexual contact treated by medicating with tadalafil (Cialis) C. Anorgasmia treated by vardenafil (Levitra) D. Anorgasmia treated by sensate focus exercises

ANS: A The nurse should recognize that this sexual aversion disorder is characterized by an avoidance of genital sexual contact. Sexual aversion implies anxiety, fear, or disgust in sexual situations. Sexual aversion can be treated by systematic desensitization.

A client diagnosed with depression and substance abuse has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? A. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. B. Sedative-hypnotics are expensive and have numerous side effects. C. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. D. Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.

ANS: A The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The effects of central nervous system depressants are additive with one another and are capable of producing physiological and psychological dependence.

A lonely, depressed divorcée has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individual's situation? A. The individual is experiencing psychological dependency. B. The individual is experiencing physical dependency. C. The individual is experiencing substance dependency. D. The individual is experiencing social dependency.

ANS: A The nurse should use the term "psychological dependency" to best describe this client's situation. A client is considered to be psychologically dependent on a substance when there is an overwhelming desire to use a substance in order to produce pleasure or avoid discomfort.

Which nursing diagnosis should be prioritized when providing care to a client diagnosed with paranoid personality disorder? A. Risk for violence: directed toward others R/T suspicious thoughts B. Risk for suicide R/T altered thought C. Altered sensory perception R/T increased levels of anxiety D. Social isolation R/T inability to relate to others

ANS: A The priority nursing diagnosis for a client diagnosed with paranoid personality disorder should be risk for violence: directed toward others R/T suspicious thoughts. Clients diagnosed with paranoid personality disorder have a pervasive distrust and suspiciousness of others that may result in hostile actions to protect self. They are often tense and irritable, which increases the likelihood of violent behavior.

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? A. Risk for injury R/T central nervous system stimulation B. Disturbed thought processes R/T tactile hallucinations C. Ineffective coping R/T powerlessness over alcohol use D. Ineffective denial R/T continued alcohol use despite negative consequences

ANS: A The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

To promote self-reliance, how should a psychiatric nurse best conduct medication administration? A. Encourage clients to request their medications at the appropriate times. B. Refuse to administer medications unless clients request them at the appropriate times. C. Allow the clients to determine appropriate medication times. D. Take medications to the clients' bedside at the appropriate times.

ANS: A The psychiatric nurse promoting self-reliance would encourage clients to request their medications at the appropriate times. Nurses are responsible for the management of medication administration on inpatient psychiatric units; however, nurses must work with clients to foster independence and provide experiences that would foster increased self-esteem.

Which nursing intervention strategy is most appropriate to implement initially with a suicidal client? A. Ask a direct question such as, "Do you ever think about killing yourself?" B. Ask client, "Please rate your mood on a scale from 1 to 10." C. Establish a trusting nurse-client relationship. D. Apply the nursing process to the planning of client care.

ANS: A The risk of suicide is greatly increased if the client has suicidal ideations, has developed a plan, and particularly if means exist for the client to execute the plan.

A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred? A. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder." B. "Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder." C. "Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks." D. "Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks."

ANS: A The student indicates learning has occurred when he or she states that clonazepam is a particularly effective treatment for panic disorder. Clonazepam is a type of benzodiazepine that can be abused and lead to physical dependence and tolerance. It can be used on an as-needed basis to reduce anxiety and its related symptoms.

In defiance of parental wishes, a Japanese teenager succumbs to peer pressure and gets a tattoo. According to Bowen's family systems theory, how should the community health nurse interpret the teenager's action? A. The teenager is attempting to differentiate self. B. The teenager is triangulating self. C. The teenager is cutting self off emotionally. D. The teenager is exhibiting antisocial traits.

ANS: A The teenager is taking on some of the cultural values of peers and is beginning to develop a unique identity. This process is called differentiation and is a normal task of adolescence.

A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess? A. Gross tremors, delirium, hyperactivity, and hypertension B. Disorientation, peripheral neuropathy, and hypotension C. Oculogyric crisis, amnesia, ataxia, and hypertension D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension

ANS: A Withdrawal is defined as the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. Symptoms can include gross tremors, delirium, hyperactivity, hypertension, nausea, vomiting, tachycardia, hallucinations, and seizures.

Which of the following nursing diagnoses could be appropriate for an adult survivor of incest? (Select all that apply.) A. Low self-esteem B. Powerlessness C. Disturbed personal identity D. Knowledge deficit E. Noncompliance

ANS: A, B An adult survivor of incest would most likely have low self-esteem and a sense of powerlessness. Adult survivors of incest are at risk for developing post-traumatic stress disorder, sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating disorders, and substance abuse disorders. Disturbed personal identity refers to an inability to distinguish between self and nonself and is seen in disorders such as autistic disorders, borderline personality disorders, dissociative disorders, and gender identity disorders.

A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? (Select all that apply.) A. Binge eating with obesity B. Bingeing and purging with a diagnosis of bulimia nervosa C. Weight loss with a diagnosis of anorexia nervosa D. Amenorrhea with a diagnosis of anorexia nervosa E. Emaciation with a diagnosis of bulimia nervosa

ANS: A, B The nurse should identify that topiramate (Topamax) is the drug of choice when treating binge eating with obesity and bingeing and purging with a diagnosis of bulimia nervosa. Topiramate (Topamax) is a novel anticonvulsant used in the long-term treatment of binge-eating disorder with obesity. The use of Topamax results in a significant decline in mean weekly binge frequency and significant reduction in body weight. With the use of this medication, episodes of bingeing and purging were decreased in clients diagnosed with bulimia nervosa.

After a teenager reveals that he is gay, the father responds by beating him. The next morning, the teenager is found hanging in his closet. Which paternal emotions should a nurse anticipate? (Select all that apply.) A. Shock and disbelief B. Guilt and remorse C. Anger and resentment D. Bargaining and depression E. Denial and rationalization

ANS: A, B, C Suicide of a family member can induce a whole gamut of feelings in the survivors. Shock, disbelief, guilt, remorse, anger, and resentment are all feelings that may be experienced by this father.

Which statements represent positive outcomes for clients diagnosed with narcissistic personality disorder? (Select all that apply.) A. The client will relate one empathetic statement toward another client in group by day 2. B. The client will identify one personal limitation by day 1. C. The client will acknowledge one strength that another client possesses by day 2. D. The client will list four personal strengths by day 3. E. The client will list two lifetime achievements by discharge.

ANS: A, B, C The nurse should determine that appropriate outcomes for a client diagnosed with narcissistic personality disorder include relating empathetic statements to other clients, identifying one personal limitation, and acknowledging one strength in another client. An exaggerated sense of self-worth, a lack of empathy, and exploitation of others are characteristics of narcissistic personality disorder.

Laboratory results reveal decreased levels of prolactin in a client diagnosed with schizophrenia. When assessing the client, which symptoms should a nurse expect to observe?(Select all that apply.) A. Apathy B. Social withdrawal C. Anhedonia D. Auditory hallucinations E. Delusions

ANS: A, B, C The nurse should expect that a client with decreased levels of prolactin would experience apathy, social withdrawal, and anhedonia. Decreased levels of prolactin can cause depression which would result in the above symptoms.

A client diagnosed with an adjustment disorder asks the nurse, "Tell me about medications that will cure this problem." Which of the following are appropriate nursing replies? (Select all that apply.) A. "Medications can interfere with your ability to find a more permanent problem solution." B. "Medications may mask the real problem at the root of this diagnosis." C. "Adjustment disorders are not commonly treated with medications." D. "Psychoactive drugs carry the potential for physiological and psychological dependence." E. "Psychoactive drugs will be prescribed only if your problems persist for more than 3 months."

ANS: A, B, C, D Adjustment disorder is not commonly treated with medications because of temporary effects, masking the real problem, interfering with finding a permanent solution, and the potential for addiction.

A client has been diagnosed with pathological gambling. The client's family inquires about their brother's behavior that led to this diagnosis. Which of the following information should the clinic nurse provide? (Select all that apply.) A. Your brother has been preoccupied with thoughts about gambling. B. Your brother has been gambling with increased amounts of money to gain excitement. C. Your brother has tried but failed to control his gambling. D. Your brother's gambling is a result of manic behavior. E. Your brother has lied to you about the extent of his gambling.

ANS: A, B, C, E The DSM-IV-TR criteria for the diagnosis of pathological gambling include all and more of the behaviors presented. The gambling behavior cannot be better accounted for by a manic episode.

A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to a nurse that discharge teaching about this medication has been successful? (Select all that apply.) A. "I'll have to let my surgeon know about this medication before I have my cholecystectomy." B. "Guess I will have to give up my glass of red wine with dinner." C. "I'll have to be very careful about reading food and medication labels." D. "I'm going to miss my caffeinated coffee in the morning." E. "I'll be sure not to stop this medication abruptly."

ANS: A, B, C, E The nurse should evaluate that teaching has been successful when the client states that phenelzine (Nardil) should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can have negative interactions with other medications. The client needs to tell other physicians about taking MAOIs due to the risk of drug interactions.

Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with substance-abuse disorders? (Select all that apply.) A. "I am easily manipulated and need to work on this prior to caring for these clients." B. "Because of my father's alcoholism, I need to examine my attitude toward these clients." C. "I need to review the side effects of the medications used in the withdrawal process." D. "I'll need to set boundaries to maintain a therapeutic relationship." E. "I need to take charge when dealing with clients diagnosed with substance disorders."

ANS: A, B, D The nurse should examine personal bias and preconceived negative attitudes prior to caring for clients diagnosed with substance-abuse disorders. A deficit in this area may affect the nurse's ability to establish therapeutic relationships with these clients.

When planning care for women in abusive relationships, which of the following information is important for the nurse to consider? (Select all that apply.) A. It often takes several attempts before a woman leaves an abusive situation. B. Substance abuse is a common factor in abusive relationships. C. Until children reach school age, they are usually not affected by parental discord. D. Women in abusive relationships usually feel isolated and unsupported. E. Economic factors rarely play a role in the decision to stay in abusive relationships.

ANS: A, B, D When planning care for women who have been victims of domestic abuse, the nurse should be aware that it often takes several attempts before a woman leaves an abusive situation, that substance abuse is a common factor in abusive relationships, and that women in abusive relationships usually feel isolated and unsupported. Children can be affected by domestic violence from infancy, and economic factors often play a role in the victim's decision to stay.

Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia? (Select all that apply.) A. Group therapy B. Medication management C. Deterrent therapy D. Supportive family therapy E. Social skills training

ANS: A, B, D, E The nurse should recognize that group therapy, medication management, supportive family therapy, and social skills training all play an integral part in rehabilitative programs for clients diagnosed with schizophrenia. Schizophrenia results from various combinations of genetic predispositions, biochemical dysfunctions, physiological factors, and psychological stress. Effective treatment requires a comprehensive, multidisciplinary effort.

Which of the following characteristics should a nurse identify as "normal" in the development of human sexuality for an 11-year-old child? (Select all that apply.) A. The child experiments with masturbation. B. The child may experience homosexual play. C. The child shows little interest in the opposite sex. D. The child shows little concern about physical attractiveness. E. The child is unlikely to want to undress in front of others.

ANS: A, B, E The nurse should identify that experimenting with masturbation and homosexual play and not wanting to undress in front of others are characteristics that are normal in the development of human sexuality in an 11-year-old child. Interest in the opposite sex usually increases during this age, and children often become self-conscious about their bodies.

A nursing instructor is teaching students about cirrhosis of the liver. Which of the following student statements about the complications of hepatic encephalopathy should indicate that further student teaching is needed? (Select all that apply.) A. "A diet rich in protein will promote hepatic healing." B. "This condition leads to a rise in serum ammonia resulting in impaired mental functioning." C. "In this condition, blood accumulates in the abdominal cavity." D. "Neomycin and lactulose are used in the treatment of this condition." E. "This condition is caused by the inability of the liver to convert ammonia to urea."

ANS: A, C The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing and that this condition causes blood to accumulate in the abdominal cavity (ascites), because these are incorrect statements. The treatment of hepatic encephalopathy requires abstention from alcohol, temporary elimination of protein from the diet, and reduction of intestinal ammonia using neomycin or lactulose. This condition occurs in response to the inability of the liver to convert ammonia to urea for excretion.

A nursing student is developing a study guide related to historical facts about suicide. Which of the following facts should the student include? (Select all that apply.) A. In the Middle Ages, suicide was viewed as a selfish and criminal act. B. During the Roman Empire, suicide was treated by incineration of the body. C. Suicide was an offense in ancient Greece, and a common site burial was denied. D. During the Renaissance, suicide was discussed and viewed more philosophically. E. Old Norse traditionally set a person who committed suicide adrift in the North Sea.

ANS: A, C, D These are true historical facts about suicide and should be included in the student's study guide.

A nurse is caring for a group of clients within the DSM-IV-TR cluster B category of personality disorders. Which factors should the nurse consider when planning client care? (Select all that apply.) A. These clients have personality traits that are deeply ingrained and difficult to modify. B. These clients need medications to treat the underlying physiological pathology. C. These clients use manipulation, making the implementation of treatment problematic. D. These clients have poor impulse control that hinders compliance with a plan of care. E. These clients commonly have secondary diagnoses of substance abuse and depression.

ANS: A, C, D, E The nurse should consider that individuals diagnosed with cluster B-type personality disorders have deeply ingrained personality traits, use manipulation, have poor impulse control, and often have secondary diagnoses of substance abuse and/or depression. This cluster includes antisocial, borderline, histrionic, and narcissistic personality disorders.

Which of the following nursing interventions fall within the standards of psychiatric-mental health clinical nursing practice for a nurse generalist? (Select all that apply.) A. Assist clients to perform activities of daily living. B. Consult with other clinicians to provide services for clients and effect system change. C. Encourage clients to discuss triggers for relapse. D. Use prescriptive authority in accordance with state and federal laws. E. Educate families about signs and symptoms of alcohol dependence and withdrawal.

ANS: A, C, E Assisting clients to perform daily living activities, encouraging clients to discuss triggers, and educating families are nursing interventions that fall within the standards of psychiatric clinical nursing practice for a nurse generalist. Psychiatric-mental health advanced practice registered nurses can consult with other clinicians and use prescriptive authority.

A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia. The therapeutic effect of this medication would most effectively address which of the following symptoms? (Select all that apply.) A. Somatic delusions B. Social isolation C. Gustatory hallucinations D. Flat affect E. Clang associations

ANS: A, C, E The nurse should expect that risperidone (Risperdal) would be effective treatment for somatic delusions, gustatory hallucinations, and clang associations. Risperidone is an atypical antipsychotic that has been effective in the treatment of the positive symptoms of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms.

A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.) A. Sad mood on most days B. Mood rating of 2/10 for the past 6 months C. Labile mood D. Sad mood for the past 3 years after spouse's death E. Pressured speech when communicating

ANS: A, D The nurse should anticipate that a client with a diagnosis of dysthymic disorder would experience a sad mood on most days for more than 2 years. The essential feature of dysthymia is a chronically depressed mood which can have an early or late onset.

In evaluating nursing interventions, which of the following types of questions would a nurse use to gather information from a client diagnosed with an impulse control disorder? (Select all that apply.) A. Can the client demonstrate the ability to delay gratification? B. Does the client demonstrate evidence of progression along the grief response? C. Can the client accomplish activities of daily living independently? D. Does the client verbalize symptoms of tension preceding unacceptable behavior? E. Does the client verbalize the unacceptability of maladaptive behaviors?

ANS: A, D, E A client diagnosed with an impulse control disorder should not have difficulty accomplishing activities of daily living or progressing through the grief process. These types of questions would be appropriate for clients diagnosed with adjustment disorders, not impulse control disorders.

A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client? A. "I'm not going to use heroin ever again. I know I've got the willpower to do it this time." B. "I cannot control my use of heroin. It's stronger than I am." C. "I'm going to get all my children back. They need their mother." D. "Once I deal with my childhood physical abuse, recovery should be easy."

ANS: B A positive prognosis is more likely when a client admits that he or she is addicted to a substance and has a loss of control. One of the first steps in accepting treatment is for the client to admit powerlessness over the substance.

Which is a correctly written, appropriate outcome for a client with a history of suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating self? A. The client will not physically harm self. B. The client will express three positive self-attributes by day 4. C. The client will reveal a suicide plan. D. The client will establish a trusting relationship with the nurse by day 1.

ANS: B Although the client has a history of suicide attempts, the current problem is isolative behaviors based on low self-esteem. Outcomes should be client centered, specific, realistic, measureable, and contain a time frame.

A client is diagnosed with intermittent explosive disorder. The clinic nurse should anticipate teaching about which medication? A. Citalopram (Celexa) B. Risperidone (Risperdal) C. Fluvoxamine (Luvox) D. Isocarboxazid (Marplan)

ANS: B An antipsychotic like Risperdal can be prescribed for intermittent explosive disorder. An antidepressant is not the usual drug of choice for this disorder.

A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization? A. The client will refrain from ritualistic behaviors during daylight hours. B. The client will wake early enough to complete rituals prior to breakfast. C. The client will participate in three unit activities by day 3. D. The client will substitute a productive activity for rituals by day 1.

ANS: B An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to breakfast. The nurse should also provide a structured schedule of activities and later in treatment begin to gradually limit the time allowed for rituals.

A recently widowed client reports a fear of intimacy due to an inability to achieve and sustain an erection. He has become isolative, has difficulty sleeping, and has recently lost weight. Which correctly written nursing diagnosis should be prioritized for this client? A. Risk for situational low self-esteem AEB inability to achieve an erection B. Sexual dysfunction R/T dysfunctional grieving AEB inability to experience orgasm C. Social isolation R/T low self-esteem AEB refusing to engage in dating activities D. Disturbed body image R/T penile flaccidity AEB client statements

ANS: B Based on the client's symptoms, the nurse should prioritize the nursing diagnosis of sexual dysfunction R/T dysfunctional grieving AEB inability to experience orgasm. The nurse should assess the client's mood and level of energy because depression and fatigue can decrease desire for participation in sexual activity.

A client is taking chlordiazepoxide (Librium) for generalized anxiety disorder symptoms. In which situation should a nurse recognize that this client is at greatest risk for drug overdose? A. When the client has a knowledge deficit related to the effects of the drug B. When the client combines the drug with alcohol C. When the client takes the drug on an empty stomach D. When the client fails to follow dietary restrictions

ANS: B Both Librium and alcohol are central nervous system depressants. In combination, these drugs have an additive effect and can suppress the respiratory system leading to respiratory arrest and death.

A newly admitted client diagnosed with major depressive disorder states, "I have never considered suicide." Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply? A. "I'm glad you shared this. There is nothing to worry about. We will handle it together." B. "Bringing this up is a very positive action on your part." C. "We need to talk about the things you have to live for." D. "I think you should consider all your options prior to taking this action."

ANS: B By admitting to the staff a suicide plan, this client has taken responsibility for possible personal actions and expresses trust in the nurse. Therefore, the client may be receptive to continuing a safety plan. Recognition of this achievement reinforces this adaptive behavior.

A nurse working with a client diagnosed with bulimia nervosa asks the client to recall a time in life when food could be consumed without purging. Which is the purpose of this nursing intervention? A. To gain additional information about the progression of the disease process B. To emphasize that the client is capable of consuming food without purging C. To incorporate specific foods into the meal plan to reflect pleasant memories D. To assist the client to become more compliant with the treatment plan

ANS: B By asking the client to recall a time in life when food could be consumed without purging, the nurse is assessing previously successful coping strategies. This information can be used by the client to modify maladaptive behaviors in the present and future.

A client diagnosed with cluster "C" traits sits alone and ignores other's attempts to converse. When ask to join a group the client states, "No thanks." In this situation, which should the nurse assign as an initial nursing diagnosis? A. Fear R/T hospitalization B. Social isolation R/T poor self-esteem C. Risk for suicide R/T to hopelessness D. Powerlessness R/T dependence issues

ANS: B Clients diagnosed with cluster "C" traits are described as anxious and fearful. The DSM-IV-TR divides cluster "C" personality disorders into three categories: avoidant, dependent, and obsessive-compulsive. Anxiety and fear contribute to social isolation.

While improving, a client demands to have a phone installed in the intensive care unit (ICU) room. When a nurse states, "This is not allowed. It is a unit rule." The client angrily demands to see the doctor. Which approach should the nurse use in this situation? A. Provide an explanation for the necessity of the unit rule. B. Assist the client to discuss anger and frustrations. C. Call the physician and relay the request. D. Arrange for a phone to be installed in the client's unit room.

ANS: B Clients who demand special privileges may be diagnosed with narcissistic personality disorder. The best approach in this situation is for the nurse to identify the function that anger, frustration, and rage serve for the client. The verbalization of feelings may help the client to gain insight into his or her behavior.

A nursing instructor is teaching about the importance of healthy family member expectations for newly blended families. Which student statement indicates a need for further instruction? A. "Healthy family member expectations should be flexible." B. "Healthy family member expectations should be conforming." C. "Healthy family member expectations should be individual." D. "Healthy family member expectations should be realistic."

ANS: B Conforming is a behavior that interferes with adaptive functioning in terms of family member expectations. This student statement indicates a need for further instruction. Realism, flexibility, and individuality are all characteristics of healthy family member expectations.

A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, "I'm feeling a lot better so you can stop watching me. I have taken up too much of your time already." Which is the best nursing reply? A. "I really appreciate your concern but I have been ordered to continue to watch you." B. "Because we are concerned about your safety, we will continue to observe you." C. "I am glad you are feeling better. The treatment team will consider your request." D. "I will forward you request to your psychiatrist because it is his decision."

ANS: B Often suicidal clients resist personal monitoring which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected.

After a spouse dies, a client is diagnosed with adjustment disorder with depressed mood. Client symptoms include chronic migraines, feelings of hopelessness, social isolation, and self-care deficit. Which outcome would be most appropriate to direct the focus of this client's care? A. The client will not cope with stress by impulsive behaviors by discharge. B. The client will accomplish activities of daily living independently by discharge. C. The client will be able to cope effectively by delaying gratification by discharge. D. The client will verbalize a positive body image by discharge.

ANS: B Impulsive behaviors and the inability to delay gratification are symptoms of impulse control, not adjustment disorders. There is no evidence presented that the client has a body image distortion. Setting an outcome of independent self-care will direct nursing interventions toward encouraging the client to meet self-care needs.

Parents of a 3-year-old have noticed an improvement in behavior because of using a "time out" behavioral approach. What aspect of "time out" therapy may be responsible for this child's improved behavior? A. "Negative reinforcement discourages maladaptive behavior." B. "Positive reinforcement is removed." C. "Covert sensitization is being applied. D. "Reciprocal inhibition is eliminated."

ANS: B In a "time out," the positive reinforcement of attention is removed from the child during inappropriate behavior.

A client is assigned the nursing diagnosis of impaired social interaction R/T socio-cultural differences AEB client stating, "Although I'd like to, I don't join in because I don't speak the language so good." Which correctly written outcome addresses this client's problem? A. The client will collaborate with nursing staff to set specific goals by day 3. B. The client will participate in one group activity of choice by day 2. C. The client will express a desire to interact with others. D. The client will become increasingly independent by discharge.

ANS: B In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client need or to the situation.

An adolescent client was recently admitted to the psychiatric unit because of impulsivity and acting-out behavior at school. The nurse should initially implement which nursing action? A. Redirect the client to activities to decrease stress. B. Explain the unit rules and consequences of breaking the rules. C. Place the client on close observation to insure a trusting relationship. D. Administer an anti-anxiety medication.

ANS: B It is important for the nurse to initially explain the unit rules and consequences of breaking the rules. It is imperative that consequences of rule infractions are explained early in treatment to avoid misunderstanding and manipulation.

A client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Expressions of poor self-esteem

ANS: B Lack of attention to grooming and hygiene is the only behavioral symptom presented. Depressed clients do not care enough about themselves to participate in grooming and hygiene.

An adolescent comes from a dysfunctional family where physical and verbal abuse prevail. At school this adolescent bullies and fights with classmates. Based on principles of behavior therapy, what is the probable source of this behavior? A. Shaping B. Modeling C. Premack principle D. Reciprocal inhibition

ANS: B Modeling is the learning of new behaviors by imitating the behaviors of others. This adolescent, witnessing physical and verbal abuse in the home, models this behavior in school.

A nursing instructor is teaching about the behavior technique of modeling. When asked to give an example of this behavioral intervention, which student statement meets the learning objective? A. "A child is first rewarded for using a spoon to eat and then rewarded for using a fork, and finally rewarded for cutting food with a knife." B. "An adolescent imitates Dad by using and caring for tools appropriately." C. "A client and therapist agree to conditions of therapy stating explicitly in writing the behavior change that is desired." D. "A mother tells her child that television can be watched only after homework is completed."

ANS: B Modeling refers to the learning of new behaviors by imitating the behavior of others.

A pessimistic client expresses low self-worth, has much difficulty making decisions, avoids positions of responsibility, and has a behavioral pattern of "suffering" in silence. Which underlying cause of this client's personality disorder should a nurse recognize? A. "Nurturance was provided from many sources, and independent behaviors were encouraged." B. "Nurturance was provided exclusively from one source, and independent behaviors were discouraged." C. "Nurturance was provided exclusively from one source, and independent behaviors were encouraged." D. "Nurturance was provided from many sources, and independent behaviors were discouraged."

ANS: B Nurturance provided from one source and discouragement of independent behaviors can attribute to the etiology of dependent personality disorder. Dependent behaviors may be rewarded by a parent who is overprotective and discourages autonomy.

Which nursing diagnosis would best describe the problems evidenced by the following client symptoms: avoidance, poor concentration, nightmares, hypervigilance, exaggerated startle response, detachment, emotional numbing, and flashbacks? A. Ineffective coping B. Post-trauma syndrome C. Complicated grieving D. Panic anxiety

ANS: B Post-trauma syndrome is defined as a sustained maladaptive response to a traumatic, overwhelming event. This nursing diagnosis addresses the problems experienced by clients diagnosed with post-traumatic stress disorder.

A client is diagnosed with an anxiety disorder. The nurse counselor recommends intervention with the behavioral technique of reciprocal inhibition. The client asks, "What's that?" Which is the most appropriate nursing reply? A. "At the beginning of this intervention, a contract will be drawn up explicitly stating the behavior change agreed upon." B. "By introducing an adaptive behavior that is mutually exclusive to your maladaptive behavior, we will expect subsequent behavior to improve." C. "Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety." D. "In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate."

ANS: B Reciprocal inhibition decreases or eliminates an undesired behavior by introducing a more adaptive behavior that is incompatible with the undesired behavior.

During the implementation phase of the nursing process, a nurse is teaching an adult with a cochlear implant about medications. Which modification in the teaching plan would be the most appropriate for this client? A. Using repetition B. Speaking directly face-to-face C. Employing the use of sign language D. Providing large-print materials

ANS: B Speaking face-to-face is an appropriate way to teach individuals with alterations in hearing.

Which individual would most likely be diagnosed with intermittent explosive disorder? A. A client diagnosed with antisocial personality disorder who attacks the nursing staff B. A client diagnosed with diabetes mellitus who has a history of multiple severe assaultive acts C. A client diagnosed with schizophrenia who sets fires because of command hallucinations D. A client diagnosed with alcohol dependence who severely beats wife while intoxicated

ANS: B The DSM-IV-TR criteria for the diagnosis of intermittent explosive disorder state that the aggressive episodes are not better accounted for by another mental disorder like antisocial personality disorder or schizophrenia. Also, the aggressive episodes are not due to the direct physiological effect of a substance such as alcohol.

During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the most appropriate nursing statement to address this behavior? A. "You are very disrespectful. You need to learn to control yourself." B. "I understand that you are angry, but this behavior will not be tolerated." C. "What behaviors could you modify to improve this situation?" D. "What anti-personality-disorder medications have helped you in the past?"

ANS: B The appropriate nursing statement is to reflect the client's feeling while setting firm limits on behavior. Clients diagnosed with antisocial personality disorder have a low tolerance for frustration, see themselves as victims, and use projection as a primary ego defense mechanism. Antidepressants and anxiolytics are used for symptom relief; however, there are no specific medications targeted for the diagnosis of a personality disorder.

A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this client's safety upon discharge? A. Provide a 6-month supply of Elavil to ensure long-term compliance. B. Provide a 1-week supply of Elavil with refills contingent on follow-up appointments. C. Provide a pill dispenser as a memory aid. D. Provide education regarding the avoidance of foods containing tyramine.

ANS: B The health-care provider should provide a 1-week supply of Elavil with refills contingent on follow-up appointments as an appropriate intervention to maintain the client's safety. Tricyclic antidepressants have a narrow therapeutic range and can be used in overdose to commit suicide. Distributing limited amounts of the medication decreases this potential.

A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred? A. "Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling." B. "Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs." C. "They tend to develop few relationships because they are strongly independent but generally maintain deep affection." D. "They pay particular attention to details which can frustrate the development of relationships."

ANS: B The instructor should evaluate that learning has occurred when the student describes clients diagnosed with histrionic personality disorder as having shallow, fleeting interpersonal relationships that serve their dependency needs. Histrionic personality disorder is characterized by colorful, dramatic, and extroverted behavior. These individuals also have difficulty maintaining long-lasting relationships.

A client diagnosed with schizophrenia functions well and is bright, spontaneous, and interactive during hospitalization but then decompensates after discharge. What does the milieu provide that may be missing in the home environment? A. Peer pressure B. Structured programming C. Visitor restrictions D. Mandated activities

ANS: B The milieu, or therapeutic community, provides the client with structured programming that may be missing in the home environment. The therapeutic community provides a structured schedule of activities in which interpersonal interaction and communication with others are emphasized. In the milieu, time is also devoted to personal problems and focus groups.

A nursing student questions an instructor regarding the order for fluvoxamine (Luvox) 300 mg daily for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor reply is most accurate? A. "High doses of tricyclic medications will be required for effective treatment of OCD." B. "Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD." C. "The dose of Luvox is low due to the side effect of daytime drowsiness and nighttime insomnia." D. "The dosage of Luvox is outside the therapeutic range and needs to be questioned."

ANS: B The most accurate instructor response is that SSRI doses, in excess of what is effective for treating depression, may be required in the treatment of OCD. SSRIs have been approved by the U.S. Food and Drug Administration for the treatment of OCD. Common side effects include headache, sleep disturbances, and restlessness.

A client is brought to an emergency department after being violently raped. Which nursing action is appropriate? A. Discourage the client from discussing the event as this may lead to further emotional trauma. B. Remain nonjudgmental and actively listen to the client's description of the event. C. Meet the client's self-care needs by assisting with showering and perineal care. D. Provide cues, based on police information, to encourage further description of the event.

ANS: B The most appropriate nursing action is to remain nonjudgmental and actively listen to the client's description of the event. It is important to also communicate to the victim that he or she is safe and that it is not his or her fault. Nonjudgmental listening provides an avenue for client catharsis needed in order to begin the process of healing.

From a behavioral perspective, which nursing intervention is most appropriate when caring for a client diagnosed with borderline personality disorder? A. Seclude the client when inappropriate behaviors are exhibited. B. Contract with the client to reinforce positive behaviors with unit privileges. C. Teach the purpose of antianxiety medications to improve medication compliance. D. Encourage the client to journal feelings to improve awareness of abandonment issues.

ANS: B The most appropriate nursing intervention from a behavioral perspective is to contract with the client to reinforce positive behaviors with unit privileges. Behavioral strategies offer reinforcement for positive change.

A family member is seeking advice about an elderly parent who seems to worry unnecessarily about everything. The family member states, "Should I seek psychiatric help for my mother?" Which is an appropriate nursing reply? A. "My mother also worries unnecessarily. I think it is part of the aging process." B. "Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning." C. "From what you have told me, you should get her to a psychiatrist as soon as possible." D. "Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications."

ANS: B The most appropriate reply by the nurse is to explain to the family member that anxiety is considered abnormal when it is out of proportion and impairs functioning. Anxiety is a normal reaction to a realistic danger or threat to biological integrity or self-concept.

A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effective of suicide on family dynamics. B. Carefully and unobtrusively observe based on assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self esteem.

ANS: B The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe based on assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe.

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia? A. Establishing personal contact with family members. B. Being reliable, honest, and consistent during interactions. C. Sharing limited personal information. D. Sitting close to the client to establish rapport.

ANS: B The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the client's needs and maintain a calm attitude when dealing with agitated behavior.

During an admission assessment, a nurse asks a client diagnosed with schizophrenia, "Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption? A. Delusions of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur

ANS: B The nurse is assessing the client for delusions of influence when asking if the client has ever felt that objects or persons have control of the client's behavior. Delusions of control or influence are manifested when the client believes that his or her behavior is being influenced. An example would be if a client believes that a hearing aid receives transmissions that control personal thoughts and behaviors.

Which statement indicates that the nurse is acting as an advocate for a client who has recently made a suicide attempt? A. "I must observe you continually for 1 hour in order to keep you safe." B. "Let's confer with the treatment team about the triggers to your attempt that we discussed." C. "You must have been very upset to do what you did today." D. "Are you currently thinking about harming yourself?"

ANS: B The nurse is functioning in an advocacy role when collaborating with the client and treatment team to discuss client problems.

A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance dependence? A. Narcotic pain medication is contraindicated for all clients with active substance-abuse problems. B. Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. C. There is no need to assess the client for substance dependence. There is an obvious PCA malfunction. D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

ANS: B The nurse should assess the client for substance dependence because clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics, and require increased doses to achieve effective pain control. Cross-tolerance occurs when one drug lessened the client's response to another drug.

What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression can generate somatic symptoms that can mask actual physical disorders. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.

ANS: B The nurse should determine that a client with a diagnosis of major depressive disorder needs a full physical health assessment because depression can generate somatic symptoms that can mask actual physical disorders. Somatization is the process by which psychological needs are expressed in the form of physical symptoms.

The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing reply? A. "Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions." B. "Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve." C. "Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support." D. "Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed."

ANS: B The nurse should educate the family on the correlation between certain familial patterns and anorexia nervosa. Families engaging in conflict avoidance and struggling with issues of power and control may contribute to the development of this disorder.

A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? A. 50 mg/dL B. 100 mg/dL C. 250 mg/dL D. 300 mg/dL

ANS: B The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL.

Which client is a nurse most likely to admit to an inpatient facility for self-destructive behaviors? A. A client diagnosed with antisocial personality disorder B. A client diagnosed with borderline personality disorder C. A client diagnosed with schizoid personality disorder D. A client diagnosed with paranoid personality disorder

ANS: B The nurse should expect that a client diagnosed with borderline personality disorder would be most likely to be admitted to an inpatient facility for self-destructive behaviors. Clients diagnosed with this disorder often exhibit repetitive, self-mutilative behaviors. Most gestures are designed to evoke a rescue response.

A client refuses to go on a cruise to the Bahamas with his spouse due to fearing that the cruise ship will sink and all will drown. Using a cognitive theory perspective, how should a nurse explain to the spouse the etiology of this fear? A. "Your spouse may be unable to resolve internal conflicts which result in projected anxiety." B. "Your spouse may be experiencing a distorted and unrealistic appraisal of the situation." C. "Your spouse may have a genetic predisposition to overreacting to potential danger." D. "Your spouse may have high levels of brain chemicals that may distort thinking."

ANS: B The nurse should explain that from a cognitive perspective the client is experiencing a distorted and unrealistic appraisal of the situation. From a cognitive perspective, fear is described as the result of faulty cognitions.

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing reply? A. "This combination of drugs can lead to delirium tremens." B. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." C. "That's a good idea. There have been good results with the combination of these two drugs." D. "The only disadvantage would be the exorbitant cost of the MAOI."

ANS: B The nurse should explain to the client that combining an MAOI and Luvox can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread."

A client has been recently admitted to an inpatient psychiatric unit. Which intervention should the nurse plan to use to reduce the client's focus on delusional thinking? A. Present evidence that supports the reality of the situation B. Focus on feelings suggested by the delusion C. Address the delusion with logical explanations D. Explore reasons why the client has the delusion

ANS: B The nurse should focus on the client's feelings rather than attempt to change the client's delusional thinking by the use of evidence or logical explanations. Delusional thinking is usually fixed, and clients will continue to have the belief in spite of obvious proof that the belief is false or irrational.

A nurse is counseling a client diagnosed with transgenderism. Which characteristic would differentiate this disorder from transvestic fetishism? A. Clients diagnosed with transvestic fetishism are dissatisfied with their gender, whereas clients diagnosed with transgenderism are not. B. Clients diagnosed with transgenderism are dissatisfied with their gender, whereas clients diagnosed with transvestic fetishism are not. C. Clients diagnosed with transgenderism never engage in cross-dressing, whereas clients diagnosed with transvestic fetishism do. D. Clients diagnosed with transvestic fetishism never engage in cross-dressing, whereas clients diagnosed with transgenderism do.

ANS: B The nurse should identify that clients diagnosed with transgenderism are dissatisfied with their gender, whereas clients diagnosed with transvestic fetishism are not. Both clients diagnosed with transgenderism and transvestic fetishism may participate in cross-dressing.

A nurse is assessing a client diagnosed with pedophilia. What would differentiate this sexual disorder from a sexual dysfunction? A. Symptoms of sexual dysfunction include inappropriate sexual behaviors, whereas symptoms of a sexual disorder include impairment in normal sexual response. B. Symptoms of a sexual disorder include inappropriate sexual behaviors, whereas symptoms of sexual dysfunction include impairment in normal sexual response. C. Sexual dysfunction can be caused by increased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual disorders. D. Sexual disorders can be caused by decreased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual dysfunction.

ANS: B The nurse should identify that pedophilia is a sexual disorder in which individuals partake in inappropriate sexual behaviors. Sexual dysfunction involves impairment in normal sexual response. Pedophilia involves having sexual urges, behaviors, or sexually arousing fantasies involving sexual activity with a prepubescent child.

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety? A. Assess for medication noncompliance B. Note escalating behaviors and intervene immediately C. Interpret attempts at communication D. Assess triggers for bizarre, inappropriate behaviors

ANS: B The nurse should note escalating behaviors and intervene immediately to maintain this client's safety. Early intervention may prevent an aggressive response and keep the client and others safe.

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediate report to the ED physician? A. Tactile hallucinations B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration

ANS: B The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day following cessation of prolonged alcohol consumption.

A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? A. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia. B. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. C. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia. D. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.

ANS: B The nurse should recognize that positive symptoms of schizophrenia include paranoid delusions, neologisms, and echolalia. The negative symptoms of schizophrenia include flat affect, anhedonia, and anergia. Positive symptoms reflect an excess or distortion of normal functions. Negative symptoms reflect a decrease or loss of normal functions.

An anorexic client states to a nurse, "My father has recently moved back to town." Since that time the client has experienced insomnia, nightmares, and panic attacks that occur nightly. She has never married or dated and lives alone. What should the nurse suspect? A. Possible major depressive disorder B. Possible history of childhood incest C. Possible histrionic personality disorder D. Possible history of childhood physical abuse

ANS: B The nurse should suspect that this client might have a history of childhood incest. Adult survivors of incest are at risk for developing posttraumatic stress disorder, sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating disorders, and substance abuse disorders.

A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation? A. Allow the clients to apply the democratic process when developing unit rules. B. Maintain consistency of care by open communication to avoid staff manipulation. C. Allow the client spokesman to verbalize concerns during a unit staff meeting. D. Maintain unit order by the application of autocratic leadership.

ANS: B The nursing staff can best handle this situation by maintaining consistency of care by open communication to avoid staff manipulation. Clients diagnosed with borderline personality disorder can exhibit negative patterns of interaction such as clinging and distancing, splitting, manipulation, and self-destructive behaviors.

A nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. The nurse would expect which of the following behavioral therapies to be most commonly used in the treatment of phobias? (Select all that apply.) A. Benzodiazepine therapy B. Systematic desensitization C. Imploding (flooding) D. Assertiveness training E. Aversion therapy

ANS: B, C The nurse should explain to the client that systematic desensitization and imploding are the most commonly used behavioral therapies in the treatment of phobias. Systematic desensitization involves the gradual exposure of the client to anxiety-provoking stimuli. Imploding is the intervention used in which the client is exposed to extremely frightening stimuli for prolonged periods of time.

A client who is a veteran of the Gulf War is being assessed by a nurse for post-traumatic stress disorder (PTSD). Which of the following client symptoms would support this diagnosis? (Select all that apply.) A. The client has experienced symptoms of the disorder for 2 weeks. B. The client fears a physical integrity threat to self. C. The client feels detached and estranged from others. D. The client experiences fear and helplessness. E. The client is lethargic and somnolent.

ANS: B, C, D Clients diagnosed with PTSD can experience the following symptoms: fear of a physical integrity threat to self, detachment and estrangement from others, and intense fear and helplessness. Characteristic symptoms of PTSD include re-living the traumatic event, a sustained high level of arousal, and a general numbing of responsiveness.

An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.) A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressors

ANS: B, C, D The nurse should identify drastic temperature and barometric pressure changes, increased levels of melatonin, and/or variations in serotonergic functioning as contributing to the etiology of the client's symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November).

After a comprehensive assessment, correctly written nursing diagnoses developed for psychiatric clients may include which of the following components? (Select all that apply.) A. Medical judgments related to the psychiatric disorder B. Unmet client needs present at the moment C. Supporting data that validate the diagnosis D. Outcomes that will be targets for nursing interventions E. Statements of client problems of a functional nature

ANS: B, C, E A nursing diagnosis is a statement of a client's functional problem. An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A risk for diagnosis does not contain AEB because there is only a potential for the problem, it does not as yet exist.

Which of the following are accurate descriptors of a therapeutic community? (Select all that apply.) A. The unit schedule includes unlimited free time for personal reflection. B. Unit responsibilities are assigned according to client capabilities. C. A flexible schedule is determined by client needs. D. The individual is the sole focus of therapy. E. A democratic form of government exists.

ANS: B, E In a therapeutic community, the unit responsibilities are assigned according to client capability and a democratic form of government exists. Therapeutic communities are structured and provide therapeutic interventions that focus on communication and relationship-development skills.

Which client data indicate that a suicidal client is participating in a plan for safety? A. Compliance with antidepressant therapy B. A mood rating of 9/10 C. Disclosing a plan for suicide to staff D. Expressing feelings of hopelessness to nurse

ANS: C A degree of the responsibility for the suicidal client's safety is given to the client. When a client shares with staff a plan for suicide, the client is participating in a plan for safety by communicating thoughts of self-harm that would initiate interventions to prevent suicide.

How does a democratic form of self-government in the milieu contribute to client therapy? A. By setting punishments for clients who violate the community rules B. By dealing with inappropriate behaviors as they occur C. By setting community expectations wherein all clients are treated on an equal basis D. By interacting with professional staff members to learn about therapeutic interventions

ANS: C A democratic form of self-government in the milieu contributes to client therapy by setting the expectation that all clients should be treated on an equal basis. Clients participate in the decision-making and problem-solving aspects that affect treatment setting. The norms, rules, and behavioral limits are established by the staff and clients. All individuals have input.

Which adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder? A. A physically healthy client who is dependent on meeting social needs by contact with 15 cats B. A physically healthy client who has a history of depending on intense relationships to meet basic needs C. A physically healthy client who lives with parents and relies on public transportation D. A physically healthy client who is serious, inflexible, perfectionistic, and depends on rules to provide security

ANS: C A physically healthy adult client who lives with parents and relies on public transportation exhibits signs of dependent personality disorder. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior.

A newly admitted client has taken thioridazine (Mellaril) for 2 years with good symptom control. Symptoms exhibited on admission included paranoid delusions and hallucinations. The nurse should recognize which potential cause for the return of these symptoms? A. The client has developed tolerance to the antipsychotic medication. B. The client has not taken the medication with food. C. The client has not taken the medication as prescribed. D. The client has combined alcohol with the medication.

ANS: C Altered thinking can affect a client's insight into the necessity for taking antipsychotic medications consistently. When symptoms are no longer bothersome, clients may stop taking medications that cause disturbing side effects. Clients may miss the connection between taking the medications and an improved symptom profile.

How would a nurse differentiate a client diagnosed with a social phobia from a client diagnosed with a schizoid personality disorder (SPD)? A. Clients diagnosed with social phobia can manage anxiety without medications, whereas clients diagnosed with SPD can manage anxiety only with medications. B. Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social phobia are not. C. Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. D. Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social phobias tend to avoid interactions in all areas of life.

ANS: C Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. Social phobia is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others.

A nurse would expect a client diagnosed with schizotypal personality disorder to exhibit which characteristic? A. The client keeps to self and has few, if any relationships. B. The client has many brief but intense relationships. C. The client experiences incorrect interpretations of external events. D. The client exhibits lack of tender feelings toward others.

ANS: C Clients who are diagnosed with schizotypal personality disorder experience odd beliefs or magical thinking that influences behavior and is inconsistent with cultural norms. This results in incorrect interpretations of external events.

A mother tells her teenager that in order for college tuition to be paid, the teenager must quit smoking. They develop a written agreement stipulating time frames and consequences. This is an example of which technique of behavior modification? A. Shaping B. Modeling C. Contracting D. Premack principle

ANS: C Contracting occurs when the mother and teenager together develop a written agreement related to desired behavior (smoking cessation) and positive reinforcement (paid college tuition).

A nurse is caring for four clients diagnosed with major depression. When considering the client's belief system, which client would potentially be at highest risk for suicide? A. Roman Catholic B. Protestant C. Atheist D. Muslim

ANS: C Depressed men and women who consider themselves affiliated with a religion are less likely to attempt suicide than their nonreligious counterparts.

The nurse interviewed a client who was uncooperative, answered questions with minimal responses, and rarely made eye contact. Which is the most complete documentation of baseline data obtained during the interview? A. "Appears uncooperative. Exhibits characteristics of depression." B. "Maintains poor eye contact throughout interview process. Unable to answer interview questions due to depression." C. "States, 'I don't need to be here.' when discussing admission status. Maintains minimal eye contact and offers little data related to triggers for admission." D. "Unwilling to respond openly during interview."

ANS: C Documentation occurs in the implementation phase of the nursing process. All charting entries to the client's legal record should be objective and based on assessed data. Implications and generalizations should be avoided.

When a community health nurse arrives at the home of a client diagnosed with bulimia nervosa, the nurse finds the client on the floor unconscious. The client has a history of using laxatives for purging. To what would the nurse attribute this client's symptoms? A. Increased creatinine and blood urea nitrogen (BUN) levels B. Abnormal electroencephalogram (EEG) C. Metabolic acidosis D. Metabolic alkalosis

ANS: C Excessive vomiting and laxative or diuretic abuse may lead to problems with dehydration and electrolyte imbalance. The nurse should attribute this client's fainting to the loss of alkaline stool due to laxative abuse which would lead to a relative metabolic acidotic condition.

During hospitalization, an attention-seeking client has repeatedly cut self. After threatening to cut self again, the nurse states, "Here are some Band-Aids so you won't bleed on the sheets." Which is the underlying reason for this nurse's response? A. The nurse is using an aversive stimulus in response to the client's manipulative cutting behavior. B. The nurse is using negative reinforcement in response to the client's behavior. C. The nurse is minimizing reinforcement of the client's manipulative behavior with the goal of extinction. D. The nurse lacks empathy for the client's recurring self-injurious behavior.

ANS: C Extinction is the gradual decrease in frequency or disappearance of a response when a positive reinforcement is withheld. The nurse is withholding attention to the client who is exhibiting manipulative, attention-seeking behavior. The lack of positive response (attention) should cause extinction of the undesired behavior.

The following clients are seen in the emergency department. The psychiatric unit has one remaining bed. The triage nurse should expect which client to be admitted? A. The client who is experiencing tremors and has a need for medication adjustment B. The client who is experiencing anxiety and a sad mood after separation from spouse C. The client who is a single parent and hears voices stating, "Kill your infant son" D. The client who argued with her boyfriend and inflicted a superficial cut on her arm

ANS: C In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. These data are prioritized to meet client needs with an emphasis on safety.

A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse? A. Alcohol poisoning B. Cardiovascular accident (CVA) C. A reaction to disulfiram (Antabuse) D. A reaction to tannins in the red wine

ANS: C Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good deal of discomfort for the individual. Symptoms may include but are not limited to flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia.

A client states, "I hear voices that tell me that I am evil." Which outcome related to these symptoms should the nurse expect this client to accomplish by discharge? A. The client will verbalize the reason the voices make derogatory statements. B. The client will not hear auditory hallucinations. C. The client will identify events that increase anxiety and illicit hallucinations. D. The client will positively integrate the voices into the client's personality structure.

ANS: C It is unrealistic to expect the client to completely stop hearing voices. Even when compliant with antipsychotic medications, clients may still hear voices. It would be realistic to expect the client to associate stressful events with an increase in auditory hallucinations. By this recognition the client can anticipate symptoms and initiate appropriate coping skills.

An adolescent, his mother, and his soon-to-be stepfather have been in counseling with the nurse. Which statement by the nurse fosters positive relationships within this new family structure? A. "Your son should be consistently disciplined by only one parent." B. "You should not have any more children because your son will need your full attention." C. "You need to keep the lines of communication open between all of you." D. "Allow your son to make his own choices because this new situation will be stressful."

ANS: C Open lines of communication are needed for newly forming families to begin their relationship together and establish a new family structure.

A new nursing graduate asks the psychiatric nurse manager how to best classify suicide. Which is the nurse manager's best reply? A. "Suicide is a DSM-IV-TR diagnosis." B. "Suicide is a mental disorder." C. "Suicide is a behavior." D. "Suicide is an antisocial affliction."

ANS: C Suicide is not a diagnosis, disorder, or affliction. It is a behavior.

A client reports, "My friend panicked at the site of spiders. Her therapist used gradual exposure to spiders that initially made her increasingly more anxious." Which technique was the friend's therapist most likely using? A. Extinction B. Covert sensitization C. Systematic desensitization D. Reciprocal inhibition

ANS: C Systematic desensitization is a treatment for phobias in which a phobic individual is gradually exposed to increasing amounts of the phobic stimulus while practicing relaxation techniques. Eventually, the phobic stimulus causes little or no anxiety.

A home health nurse is visiting an Asian family. A married couple, their three children, and the maternal grandparents all live in the home. How should the nurse interpret the presence of the grandparents in the home? A. The parents have diffuse boundaries and have allowed the grandparental subsystem to be present. B. The grandparental subsystem is not successfully managing separation from the parental subsystem. C. Extended family living arrangements are common in some cultures. D. The nuclear family living arrangement is the preferred environment for childrearing.

ANS: C The Asian culture highly respects the elderly. Having the grandparents living in the home is not uncommon in this culture.

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility? A. By asking directly if the client has ever had a problem with alcohol B. By holistically assessing the client using the CIWA scale C. By using a screening tool such as the CAGE questionnaire D. By referring the client for physician evaluation

ANS: C The CAGE questionnaire is a screening tool used to determine the diagnosis of alcoholism. This questionnaire is composed of four simple questions. Scoring two or three "yes" answers strongly suggests a problem with alcohol.

A client has discovered that her husband is having an affair with a neighbor. During a visit to the neighbor's home, the wife steals the neighbor's diamond ring from the kitchen windowsill. What information would cause a nurse to rule out a diagnosis of kleptomania? A. The wife did not experience a sense of relief when she took the ring. B. The wife did not experience a sense of tension immediately before stealing the ring. C. The stealing was committed to express the wife's anger. D. The ring is desired by the wife for her personal use.

ANS: C The DSM-IV-TR criteria for the diagnosis of kleptomania state that an individual diagnosed with this disorder experiences a sense of tension before committing theft and relief at the time of the theft. The theft cannot be committed as an act of anger or vengeance, and the object stolen cannot be needed for personal use.

A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "His problems at work are my fault." Which is the appropriate nursing response? A. "Why do you assume responsibility for his behaviors?" B. "Codependency is a typical behavior of spouses of alcoholics." C. "Your husband needs to deal with the consequences of his drinking." D. "Do you understand what the term 'enabler' means?"

ANS: C The appropriate nursing response is to use confrontation with caring. The nurse should understand that the client's wife may be in denial and enabling the husband's behavior. Partners of clients with substance abuse must come to realize that the only behavior they can control is their own.

A client diagnosed with alcohol abuse joins a community 12-step program and states, "My life is unmanageable." How should the nurse interpret this client's statement? A. The client is using minimization as an ego defense. B. The client is ready to sign an Alcoholics Anonymous contract for sobriety. C. The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous. D. The client has met the requirements to be designated as an Alcoholics Anonymous sponsor.

ANS: C The first step of the 12-step program advocated by Alcoholics Anonymous is that clients must admit powerlessness over alcohol and that their lives have become unmanageable.

A client diagnosed with schizophrenia states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing reply? A. "Did you take your medicine this morning?" B. "You are not going to hell. You are a good person." C. "I'm sure the voices sound scary. The devil is not talking to you. This is part of your illness." D. "The devil only talks to people who are receptive to his influence."

ANS: C The most appropriate reply by the nurse is to reassure the client with an accepting attitude while not reinforcing the hallucination. Reminding the client that "the voices" are a part of his or her illness is a way to help the client accept that the hallucinations are not real.

Parents ask a nurse how they should reply when their child, diagnosed with paranoid schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply? A. "Tell him to stop discussing the voices." B. "Ignore what he is saying, while attempting to discover the underlying cause." C. "Focus on the feelings generated by the hallucinations and present reality." D. "Present objective evidence that the voices are not real."

ANS: C The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content. It is inappropriate to present logical arguments to persuade the client to accept the hallucinations as not real.

A client is experiencing a severe panic attack. Which nursing intervention would meet this client's immediate need? A. Teach deep breathing relaxation exercises B. Place the client in a Trendelenburg position C. Stay with the client and offer reassurance of safety D. Administer the ordered prn buspirone (BuSpar)

ANS: C The nurse can meet this client's immediate need by staying with the client and offering reassurance of safety and security. The client may fear for his or her life and the presence of a trusted individual provides assurance of personal safety.

A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client's depressive symptoms? A. According to psychoanalytic theory, depression is a result of anger turned inward. B. According to object-loss theory, depression is a result of abandonment. C. According to learning theory, depression is a result of repeated failures. D. According to cognitive theory, depression is a result of negative perceptions.

ANS: C The nurse should assess that this client's depressive symptoms may have resulted from repeated failures. This assessment was based on the principles of learning theory. Learning theory describes a model of "learned helplessness" in which multiple life failures cause the client to abandon future attempts to succeed.

A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurse's priority at this time? A. Give the client off-unit privileges as positive reinforcement. B. Encourage the client to share mood improvement in group. C. Increase frequency of client observation. D. Request that the psychiatrist reevaluate the current medication protocol.

ANS: C The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act-out self-destructive behaviors prior to the client attaining the full therapeutic effect of the antidepressant medication.

A fatherless, 11-year-old African American girl lives with her grandmother after the death of her mother. Her older stepbrother is very involved in her life. How should the community health nurse view this family constellation, and why? A. Abnormal; the grandmother should be concerned with issues other than childrearing. B. Abnormal; a two-parent household is the most advantageous arrangement for parenting. C. Normal; cultural variations exist in the family life cycle. D. Normal; because of their wisdom, older adults make better parenting figures.

ANS: C The nurse should be aware that cultural differences and specific events may lead to variety in family constellations. This is normal.

A client has undergone psychological testing. With which member of the interdisciplinary team should a nurse collaborate to review these results? A. The psychiatrist B. The psychiatric social worker C. The clinical psychologist D. The clinical nurse specialist

ANS: C The nurse should consult with the clinical psychologist to review psychological testing results for the client. Clinical psychologists can administer, interpret, and evaluate psychological tests to assist in the diagnostic process.

A client diagnosed with paranoid schizophrenia states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom? A. Magical thinking; administer an antipsychotic medication B. Persecutory delusions; orient the client to reality C. Command hallucinations; warn the psychiatrist D. Altered thought processes; call an emergency treatment team meeting

ANS: C The nurse should determine that the client is exhibiting command hallucinations. The nurse's legal responsibility is to warn the psychiatrist of the potential for harm. A client who is demonstrating a risk for violence could potentially become physically, emotionally, and/or sexually harmful to others or to self.

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom? A. Haloperidol (Haldol) to address the negative symptom B. Clonazepam (Klonopin) to address the positive symptom C. Risperidone (Risperdal) to address the positive symptom D. Clozapine (Clozaril) to address the negative symptom

ANS: C The nurse should expect the physician to order risperidone (Risperdal) to address the positive symptoms of schizophrenia. Risperidone (Risperdal) is an atypical antipsychotic used to reduce positive symptoms, including disturbances in content of thought (delusions), form of thought (neologisms), or sensory perception (hallucinations).

A nursing student asks an emergency department nurse, "Why does a rapist use a weapon during the act of rape?" Which nursing reply is most accurate? A. "A weapon is used to increase the victimizer's security." B. "A weapon is used to inflict physical harm." C. "A weapon is used to terrorize and subdue the victim." D. "A weapon is used to mirror learned family behavior patterns."

ANS: C The nurse should explain that a rapist uses weapons to terrorize and subdue the victim. Rape is the expression of power and dominance by means of sexual violence. Rape can occur over a broad spectrum of experience from violent attack to insistence on sexual intercourse by an acquaintance or spouse.

A client living on the beachfront seeks help with an extreme fear of crossing bridges which interferes with daily life. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this therapy should the nurse convey to the client? A. "Using your imagination, we will attempt to achieve a state of relaxation that you can replicate when faced with crossing a bridge." B. "Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response." C. "Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety." D. "In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate."

ANS: C The nurse should explain to the client that systematic desensitization exposes the client to a series of increasingly anxiety provoking steps that will gradually increase anxiety tolerance. Systematic desensitization was introduced by Joseph Wolpe in 1958 and is based on behavioral conditioning principles.

A client diagnosed with post-traumatic stress disorder is receiving paliperidone (Invega). Which symptoms should a nurse identify that warrant the need for this medication? A. Flat affect and anhedonia B. Persistent anorexia and 10 lb weight loss in 3 weeks C. Flashbacks of killing the enemy D. Distant and guarded relationships

ANS: C The nurse should identify that a client who has flashbacks of killing the enemy may need paliperidone (Invega). Paliperidone is an antipsychotic medication that can be used to treat the psychotic symptom of flashbacks.

Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)? A. Long-term treatment with diazepam (Valium) B. Acute symptom control with citalopram (Celexa) C. Long-term treatment with buspirone (BuSpar) D. Acute symptom control with ziprasidone (Geodon)

ANS: C The nurse should identify that an appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients with GAD. It takes 10 to 14 days for alleviation of symptoms but does not have the dependency concerns of other anxiolytics.

A client is diagnosed with female sexual aversion disorder. In addition to systematic desensitization techniques, which medication therapy could accompany this intervention? A. Quetiapine (Seroquel) B. Phenelzine (Nardil) C. Amoxapine (Asendin) D. Carbamazepine (Tegretol)

ANS: C The nurse should identify that medication therapy of amoxapine could complement systematic desensitization techniques. Amoxapine is a heterocyclic antidepressant that can assist in reduction of anxiety.

A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? A. The client gains 2 pounds in 1 week. B. The client focuses conversations on nutritious food. C. The client demonstrates healthy coping mechanisms that decrease anxiety. D. The client verbalizes an understanding of the etiology of the disorder.

ANS: C The nurse should identify that when a client uses healthy coping mechanisms that decrease anxiety, positive behavioral change is demonstrated. Stress and anxiety can increase bingeing which is followed by inappropriate compensatory behaviors.

Looking at a slightly bleeding paper cut, the client screams, "Somebody help me, quick! I'm bleeding. Call 911!" A nurse should identify this behavior as characteristic of which personality disorder? A. Schizoid personality disorder B. Obsessive-compulsive personality disorder C. Histrionic personality disorder D. Paranoid personality disorder

ANS: C The nurse should identify this behavior as characteristic of histrionic personality disorder. Individuals diagnosed with this disorder tend to be self-dramatizing, attention seeking, over gregarious, and seductive.

A nurse has been caring for a client diagnosed with post-traumatic stress disorder. What short-term, realistic, correctly written outcome should be included in this client's plan of care? A. The client will have no flashbacks. B. The client will be able to feel a full range of emotions by discharge. C. The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge. D. The client will refrain from discussing the traumatic event.

ANS: C The nurse should include obtaining adequate sleep without zolpidem (Ambien) by discharge as a realistic outcome for this client. Having no flashbacks and experiencing a full range of emotions are long-term not short-term outcomes for this client. Clients are encouraged to discuss the traumatic event.

During group therapy, a client diagnosed with chronic alcohol dependence states, "I would not have boozed it up if my wife hadn't been nagging me all the time to get a job. She never did think that I was good enough for her." How should a nurse interpret this statement? A. The client is using denial by avoiding responsibility. B. The client is using displacement by blaming his wife. C. The client is using rationalization to excuse his alcohol dependence. D. The client is using reaction formation by appealing to the group for sympathy.

ANS: C The nurse should interpret that the client is using rationalization to excuse his alcohol dependence. Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior.

A client diagnosed with psychosis NOS (not otherwise specified) tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client? A. Disturbed sensory perception B. Altered thought processes C. Risk for violence: directed toward others D. Risk for injury

ANS: C The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices telling him to kill someone is at risk for responding and reacting to the command hallucination. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.

A group of nurses are discussing how food is used in their families and the effects this might have on their ability to work with clients diagnosed with eating disorders. Which of these nurses will probably be most effective with these clients? A. The nurse who understands the importance of three balanced meals a day B. The nurse who permits children to have dessert only after finishing the food on their plate C. The nurse who refuses to engage in power struggles related to food consumption D. The nurse who grew up poor and frequently did not have enough food to eat

ANS: C The nurse who refuses to engage in power struggles related to food consumption will probably be most effective when dealing with clients diagnosed with eating disorders. Because of this attitude the nurse recognizes that the real issues have little to do with food or eating patterns. The nurse will be able to focus on the control issues that precipitated these behaviors.

A 13-year-old client's father has recently been deployed to Afghanistan. Since deployment, the client has begun to participate in isolative behaviors, truancy, vandalism, and fighting. The pediatric nurse practitioner should identify this behavior with which adjustment disorder? A. An adjustment disorder with anxiety B. An adjustment disorder with disturbance of conduct C. An adjustment disorder with mixed disturbance of emotions and conduct D. An adjustment disorder unspecified

ANS: C The predominant features of an adjustment disorder with mixed disturbance of emotions and conduct include symptoms of anxiety or depression as well as behaviors to include violations of rights of others, truancy, vandalism, and fighting.

A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention, and the rationale for this action? A. Administering lorazepam (Ativan) prn because the client is angry about the discovery of the note B. Establishing room restrictions because the client's threat is an attempt to manipulate the staff C. Placing this client on one-to-one suicide precautions because the more specific the plan, the more likely the client will attempt suicide D. Calling an emergency treatment team meeting because the client's threat must be addressed

ANS: C The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. The appropriate nursing diagnosis for this client would be risk for suicide.

On the first day of a client's alcohol detoxification, which nursing intervention should take priority? A. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days. B. Educate the client about the biopsychosocial consequences of alcohol abuse. C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. D. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

ANS: C The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. Chlordiazepoxide (Librium) is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal. Substitution therapy may be required to reduce life-threatening effects of the rebound stimulation of the central nervous system that occurs during withdrawal.

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices

ANS: C The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.

A nurse is seeing a client in an outpatient clinic for treatment of anorexia nervosa. Which is the most appropriate, correctly written short-term outcome for this client? A. The client will use stress-reducing techniques to avoid purging. B. The client will discuss chaos in personal life and be able to verbalize a link to purging. C. The client will gain 2 pounds prior to the next weekly appointment. D. The client will remain free of signs and symptoms of malnutrition and dehydration.

ANS: C The symptoms of anorexia nervosa do not include purging. Correctly written outcomes must be client centered, specific, realistic, measurable, and also include a time frame.

What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The client's understanding of the need for regular blood work B. The client's mood and affect score, using the facility's mood scale C. The client's cognitive ability to understand information about the medication D. The client's access to a support network willing to participate in treatment

ANS: C There are many dietary and medication restrictions when taking Nardil. A client must have the cognitive ability to understand information about the medication and which foods, beverages, and medications to eliminate when taking Nardil.

A client diagnosed with generalized anxiety states, "I know the best thing for me to do now is to just forget my worries." How should the nurse evaluate this statement? A. The client is developing insight. B. The client's coping skills are improving. C. The client has a distorted perception of problem resolution. D. The client is meeting outcomes and moving toward discharge.

ANS: C This client has a distorted perception of how to deal with the problem of anxiety. Clients should be encouraged to openly deal with anxiety and recognize the triggers that precipitate anxiety responses.

In the emergency department, a raped client appears calm and exhibits a blunt affect. The client answers a nurse's questions in a monotone using single words. How should the nurse interpret this client's responses? A. The client may be lying about the incident. B. The client may be experiencing a silent rape reaction. C. The client may be demonstrating a controlled response pattern. D. The client may be having a compounded rape reaction.

ANS: C This client is most likely demonstrating a controlled response pattern. In a controlled response pattern, the client's feelings are masked or hidden, and a calm, composed, or subdued affect is seen. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension.

A client diagnosed with bulimia nervosa is to receive fluoxetine (Prozac) by oral solution. The medication is supplied in a 100 mL bottle. The label reads 20 mg/5 mL. The doctor orders 60 mg q day. Which dose of this medication should the nurse dispense? A. 25 mL B. 20 mL C. 15 mL D. 10 mL

ANS: C Twenty mg of Prozac multiplied by three results in the calculated 60 mg daily dose ordered by the physician. Each 5 mL contains 20 mg. Five mL multiplied by three equals the liquid dosage of 15 mL.

A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the client's attending psychiatrist? A. Respirations of 22 beats/minute B. Weight gain of 8 pounds in 2 months C. Temperature of 104F (40C) D. Excessive salivation

ANS: C When assessing a client diagnosed with schizophrenia who takes an antipsychotic agent daily, the nurse should immediately address a temperature of 104F (40C). A temperature this high can be a symptom of the rare but life-threatening neuroleptic malignant syndrome.

A client is angry because her husband has forgotten their anniversary. The following week, the client is still unwilling to discuss this with her husband because she is afraid she will lose control. How should the nurse interpret this client's means of coping with anger? A. Coping by attacking B. Coping by surrendering C. Coping by avoiding D. Coping by belittling

ANS: C When coping by avoidance, differences are never acknowledged openly. The individual who disagrees avoids discussing it for fear that the other person will withdraw love or approval or become angry in response to the disagreement. Avoidance also occurs when an individual fears loss of control of his or her temper.

A nurse responsible for conducting group therapy on an eating disorder unit schedules the sessions immediately after meals. Which is the rationale for scheduling group therapy at this time? A. To shift the clients' focus from food to psychotherapy B. To prevent the use of maladaptive defense mechanisms C. To promote the processing of anxiety associated with eating D. To focus on weight control mechanisms and food preparation

ANS: C When the nurse schedules group therapy immediately after meals, the nurse is addressing the emotional issues related to eating disorders that must be resolved if these maladaptive responses are to be eliminated.

A 30-year-old client seeking therapy states, "My mom cries when she is not included in all my social activities and thinks of my friends as her own." How would the nurse describe the boundaries between this family's parent and child subsystems? A. The boundaries are rigid. B. The boundaries are restructured. C. The boundaries are enmeshed. D. The boundaries are disengaged.

ANS: C With enmeshed boundaries, family members lack individuation and experience exaggerated connectedness. The client's mother is trying to prevent independence by generating feelings of guilt.

Which of the following characteristics of accurately developed client outcomes should a nurse identify? (Select all that apply.) A. Client outcomes are specifically formulated by nurses. B. Client outcomes are not restricted by time frames. C. Client outcomes are specific and measurable. D. Client outcomes are realistically based on client capability. E. Client outcomes are formally approved by the psychiatrist.

ANS: C, D The nurse should identify that client outcomes should be specific, measurable, and realistically based on client capability. Outcomes should be derived from the diagnosis and should include a time estimate for attainment. Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, client, and significant others.

Which client statement demonstrates positive progress toward recovery from substance abuse? A. "I have completed detox and therefore am in control of my drug use." B. "I will faithfully attend Narcotic Anonymous (NA) when I can't control my carvings." C. "As a church deacon, my focus will now be on spiritual renewal." D. "Taking those pills got out of control. It cost me my job, marriage, and children."

ANS: D A client who takes responsibility for the consequences of substance abuse/dependence is making positive progress toward recovery. This client would most likely be in the working phase of the counseling process in which acceptance of the fact that substance abuse causes problems occurs.

Parents decide to try the nurse practitioner's suggestion of time out when their child misbehaves. What teaching should the nurse practitioner provide the parents? A. "Correct your child's behavior by using social isolation." B. "Ignore the child's negative behavior." C. "Add positive reinforcement for acceptable behavior." D. "Temporarily move your child to an area where behavior is not being reinforced."

ANS: D A time out is an aversive stimulus or punishment during which the client is removed from the environment where the unacceptable behavior is occurring. Usually during a time out, the person is temporarily isolated so there is no reinforcing attention. This discourages a reoccurrence of the undesired behavior.

When asked to identify principles that define the term "maladaptive behavior," which nursing student statement indicates that further teaching is needed? A. "Behavior is maladaptive when it is age inappropriate." B. "Behavior is maladaptive when it interferes with adaptive functioning." C. "Behavior is maladaptive when others misunderstand it related to cultural inappropriateness." D. "Behavior is maladaptive when there is environmental interaction with genetic endowment."

ANS: D Adaptive, not maladaptive, behaviors occur through learning processes or, more correctly, through the interaction of the environment with an individual's genetic endowment.

Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder? A. Altered thought processes R/T increased stress B. Risk for suicide R/T loneliness C. Risk for violence: directed toward others R/T paranoid thinking D. Social isolation R/T inability to relate to others

ANS: D An appropriate nursing diagnosis when working with a client diagnosed with schizoid personality disorder is social isolation R/T inability to relate to others. Clients diagnosed with schizoid personality disorder appear cold, aloof, and indifferent to others. They prefer to work in isolation and are unsociable.

Which client statement would demonstrate a common characteristic of Cluster "B" personality disorder? A. "I wish someone would make that decision for me." B. "I built this building by using materials from outer space." C. "I'm afraid to go to group because it is crowded with people." D. "I didn't have the money for the ring, so I just took it."

ANS: D Antisocial personality disorder is included in the Cluster "B" personality disorders. In this disorder there is a pervasive pattern of disregard for and violation of the rights of others.

Why are behavior modification programs the treatment of choice for clients diagnosed with eating disorders? A. These programs help clients correct distorted body image. B. These programs address underlying client anger. C. These programs help clients manage uncontrollable behaviors. D. These programs allow clients to maintain control.

ANS: D Behavior modification programs are the treatment of choice for clients diagnosed with eating disorders because these programs allow clients to maintain control. Issues of control are central to the etiology of these disorders. Behavior modification techniques aid in restoring healthy body weight.

The family of a suicidal client is very supportive and requests more facts related to caring for their family member after discharge. Which information should the nurse provide? A. Address only serious suicide threats to avoid the possibility of secondary gain. B. Promote trust by verbalizing a promise to keep suicide attempt information within the family. C. Offer a private environment to provide needed time alone at least once a day. D. Be available to actively listen, support, and accept feelings.

ANS: D Being available to actively listen, support, and accept feelings increases the potential that a client would confide suicidal ideations to family members.

A nurse enters an inpatient room and finds the family disagreeing about the client's living arrangements after discharge. Which information should the nurse provide when teaching techniques to resolve family conflicts? A. All family members should use past incidents to make their point. B. One family member should act as a gatekeeper in order to avoid family confrontation. C. One family member should act as a compromiser to preserve harmony in the family system. D. All family members should respect differing opinions and use compromise and negotiation.

ANS: D Functional families allow and respect differences among members. They learn to handle differences and conflict through negotiation and compromise.

A nurse is caring for four clients taking various medications including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? A. Tofranil B. Senequan C. Geodon D. Parnate

ANS: D Hypertensive crisis occurs in clients receiving monoamine oxidase inhibitor (MAOI) who consume foods or drugs high in tyramine content.

A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication? A. "Only oral ingestion of alcohol will cause a reaction when taking this drug." B. "It is safe to drink beverages that have only 12% alcohol content." C. "This medication will decrease your cravings for alcohol." D. "Reactions to combining Antabuse with alcohol can occur 2 weeks after stopping the drug."

ANS: D If Antabuse is discontinued, it is important for the client to understand that the sensitivity to alcohol may last for as long as 2 weeks.

During family counseling a husband states, "Every time my wife and I discuss child discipline, we get into shouting matches." The nurse instructs the couple to shout at each other for 2 weeks on Tuesdays and Thursdays for 30 minutes. What intervention is the nurse using? A. Reframing B. Restructuring the family C. Expressive psychotherapy D. Paradoxical intervention

ANS: D In a paradoxical intervention, the therapist requests the family to continue the maladaptive behavior. This removes control over the behavior from the family to the therapist. Clients are made more aware of the defeating behavior and this can lead to behavioral change.

An instructor overhears a student say, "That family seems to disagree more than agree. The family seems to be dysfunctional." To further assess the family's situation, which would be an appropriate instructor reply? A. "Families who disagree can be a challenge to the treatment team." B. "You seem very critical of the family. Do you believe that you are unable to help them?" C. "Let's bring the family in for an educational session to improve their communication." D. "What appears to trigger family disagreements?"

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. In this situation, prior to intervening with this family, the nurse needs further information about the cause of family conflicts.

A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse. What should be the initial nursing action to address this situation? A. Provide warm milk and a backrub. B. Give a sleep medication. C. Hold a relaxation group before bedtime. D. Review the client's normal sleep pattern.

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. In this situation, the nurse must initially determine the client's normal sleep patterns in order to evaluate if a true problem exists.

During an intake interview, which question would assist the nurse in gathering data about the client's judgment? A. "What brought you to the hospital? Do you know what day and season it is now?" B. "On a scale of 1 to 10, how would you rate your stress level?" C. "What does the phrase 'a rolling stone gathers no moss' mean to you?" D. "If you found a stamped, addressed envelope in the street, what would you do?"

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. The nurse presents a situation that requires the client to make a judgment call and can assess appropriate judgment based on the client's action choice.

Which nursing response would be appropriately used in the evaluation phase of the nursing process? A. "If I were in your situation, I would not repeat a behavior that has caused problems." B. "What do you think needs changing, and what do you want to do differently?" C. "What exactly will it take to carry out your plan, and what else do you need to do?" D. "This new approach seems to work for you."

ANS: D In the evaluation phase of the nursing process, the nurse evaluates progress toward attainment of the expected outcomes.

Which assumption is most reflective of a behavioral theory model? A. Mental illness is characterized by structural and biochemical alterations. B. Thought processes influence behaviors. C. All personality development has a social context. D. There is a basic relationship between stimulus and response.

ANS: D That there is a basic relationship between stimulus and response is an assumption of a behavioral theory model. The connection between a stimulus and a response is strengthened or weakened by the consequences of the response.

Which client situation should a nurse identify as reflective of the impulsive behavior that is commonly associated with borderline personality disorder? A. As the day shift nurse leaves the unit, the client suddenly hugs the nurse's arm and whispers, "The night nurse is evil. You have to stay." B. As the day shift nurse leaves the unit, the client suddenly hugs the nurse's arm and states, "I will be up all night if you don't stay with me." C. As the day shift nurse leaves the unit, the client suddenly hugs the nurse's arm, yelling, "Please don't go! I can't sleep without you being here." D. As the day shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, "I cut myself because you are leaving me."

ANS: D The client who states, "I cut myself because you are leaving me" reflects impulsive behavior that is commonly associated with the diagnosis of borderline personality disorder. Repetitive, self-mutilative behaviors are common and are generated by feelings of abandonment following separation from significant others.

A depressed 21-year-old client has lived with his mother ever since the death of his father 3 years ago. After the client received a college acceptance, the mother repeatedly states, "That's wonderful. I'll be fine all alone." How would the nurse interpret the mother's statements? A. The mother is withholding supportive messages. B. The mother is expressing denigrating remarks. C. The mother is communicating indirectly. D. The mother is using double-bind communication.

ANS: D The client's mother says she is fine with him going away to college but then tries to make him feel guilty about her being left alone. The client is in a no-win situation because his mother has given a mixed message—a double-bind communication.

During a one-to-one session with a client, the client states, "Nothing will ever get better," and "Nobody can help me." Which nursing diagnosis is most appropriate for a nurse to assign to this client at this time? A. Powerlessness R/T altered mood AEB client statements B. Risk for injury R/T altered mood AEB client statements C. Risk for suicide R/T altered mood AEB client statements D. Hopelessness R/T altered mood AEB client statements

ANS: D The client's statements indicate the problem of hopelessness. Prior to assigning either risk for injury or risk for suicide a further evaluation of the client's suicidal ideations and intent would be necessary.

A client, who recently delivered a stillborn baby, has a diagnosis of adjustment disorder unspecified. The nurse case manager should expect which client presentation that is characteristic of this diagnosis? A. The client worries continually and appears nervous and jittery. B. The client complains of a depressed mood, is tearful, and feels hopeless. C. The client is belligerent, violates the rights of others, and defaults on legal responsibilities. D. The client complains of many physical ailments, refuses to socialize, and quits her job.

ANS: D The diagnosis of adjustment disorder unspecified is assigned when the maladaptive reaction is not consistent with any of the other categories. Manifestations may include physical complaints, social withdrawal, or work or academic inhibition, without significant depressed or anxious mood.

When planning care for a client diagnosed with female sexual arousal disorder, what should a nurse document as an expected outcome of senate focus exercises? A. To initiate immediate orgasm B. To reduce anxiety by eliminating physical touch C. To focus on touching breasts and genitals D. To reduce goal-oriented demands of intercourse

ANS: D The expected outcome of senate focus exercises is to reduce goal-oriented demands of intercourse. Senate focus exercises consist of touching and being touched by another with attention focused on the physical sensations encountered. Erotic contact is gradually increased, leading to the possibility of sexual intercourse. The reduction in demands reduces performance pressures and anxiety associated with possible failure.

A psychiatric nursing instructor is teaching about the psychological effects of the diagnosis of a sexually transmitted disease (STD). Which student statement indicates that further instruction is needed? A. "STDs carry strong connotations of illicit sex and considerable social stigma." B. "STDs can cause insanity." C. "The diagnosis of HIV can generate hopelessness and helplessness." D. "Antibiotics administered in the early stages can cure all STDs."

ANS: D The instructor should identify the need for further instruction if a student states that antibiotics can cure all STDs. STDs refer to infections that are contracted primarily through sexual activities or intimate contact. An example of an incurable STD is HIV. STDs are at epidemic levels in the United States.

A nurse is assessing a client diagnosed with paranoid schizophrenia. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" Which potential symptom of this disorder is the nurse assessing? A. Thought insertion B. Paranoid delusions C. Magical thinking D. Delusions of reference

ANS: D The nurse is assessing for the potential symptom of delusions of reference. A client who believes that he or she receives messages through the radio is experiencing delusions of reference. When a client experiences these delusions, he or she interprets all events within the environment as personal references.

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? A. To assess for emotional strength B. To assess for Wernicke-Korsakoff syndrome C. To assess for tachycardia D. To assess for fine tremors

ANS: D The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, coarse tremors, and seizure activity.

Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines? A. Haloperidol (Haldol) and fluoxetine (Prozac) B. Carbamazepine (Tegretol) and donepezil (Aricept) C. Disulfiram (Antabuse) and lorazepan (Ativan) D. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

ANS: D The nurse should anticipate that a physician would order chlordiazepoxide (Librium) and phenytoin (Dilantin) for a client who has a history of complicated withdrawal from benzodiazepines. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin (Dilantin) is an anticonvulsant that would be indicated for a client who has experienced a complicated withdrawal. Complicated withdrawals may progress to seizure activity.

During an interview, which client statement indicates to a nurse that a potential diagnosis of schizotypal personality disorder should be considered? A. "I really don't have a problem. My family is inflexible, and every relative is out to get me." B. "I am so excited about working with you. Have you noticed my new nail polish: 'Ruby Red Roses'?" C. "I spend all my time tending my bees. I know a whole lot of information about bees." D. "I am getting a message from the beyond that we have been involved with each other in a previous life."

ANS: D The nurse should assess that a client who states that he or she is getting a message from the beyond indicates a potential diagnosis of schizotypal personality disorder. Individuals with schizotypal personality disorder are aloof and isolated and behave in a bland and apathetic manner. The individual experiences magical thinking, ideas of reference, illusions, and depersonalization as part of daily life.

A client diagnosed with chronic schizophrenia presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing antipsychotic medications B. Agranulocytosis and treat by administration of clozapine (Clozaril) C. Extrapyramidal symptoms and treat by administration of benztropine (Cogentin) D. Tardive dyskinesia and treat by discontinuing antipsychotic medications

ANS: D The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medications. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be an irreversible side effect of typical antipsychotic medications.

A nurse tells a client that the nursing staff will start alternating weekend shifts. Which response should a nurse identify as characteristic of clients diagnosed with obsessive-compulsive personality disorder? A. "You really don't have to go by that schedule. I'd just stay home sick." B. "There has got to be a hidden agenda behind this schedule change." C. "Who do you think you are? I expect to interact with the same nurse every Saturday." D. "You can't make these kinds of changes! Isn't there a rule that governs this decision?"

ANS: D The nurse should identify that a client diagnosed with obsessive-compulsive personality disorder would have a difficult time accepting change. This disorder is characterized by inflexibility and lack of spontaneity. Individuals diagnosed with this disorder are very serious, formal, over disciplined, perfectionistic, and preoccupied with rules.

A nurse working on an inpatient psychiatric unit is assigned to conduct a 45-minute education group. What should the nurse identify as an appropriate group topic? A. Dream analysis B. Creative cooking C. Paint by number D. Stress management

ANS: D The nurse should identify that teaching clients about stress management is an appropriate education group topic. Nurses should be able to perform the role of client teacher in the psychiatric area. Nurses need to be able to assess a client's learning readiness. Other topics for education groups include medical diagnoses, side effects of medications, and the importance of medication compliance.

During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Based on this assessment data, which antipsychotic medication would be contraindicated? A. Haloperidol (Haldol), because it is used only in elderly patients B. Clozapine (Clozaril), because of a cross-sensitivity to penicillin C. Risperidone (Risperdal), because it exacerbates symptoms of depression D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

ANS: D The nurse should know that thioridazine (Mellaril) would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine (Compazine) and thioridazine are both classified as phenothiazines.

Which teaching should the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse? A. Have ready access to a gun and learn how to use it B. Research lawyers who can aid in divorce proceedings C. File charges of assault and battery D. Have ready access to the number of a safe house for battered women

ANS: D The nurse should provide information about safe houses for battered women when working with a client who has symptoms of domestic physical abuse. Many women feel powerless within the abusive relationship and may be staying in the abusive relationship out of fear for their lives.

How would a nurse differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? A. GAD is acute in nature, and panic disorder is chronic. B. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. C. Hyperventilation is a common symptom in GAD and rare in panic disorder. D. Depersonalization is commonly seen in panic disorder and absent in GAD.

ANS: D The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.

A confused client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. What complication does a nurse suspect and what could be its possible cause? A. Neuroleptic malignant syndrome caused by ingestion of two different seratonin reuptake inhibitors (SSRIs) B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI D. Serotonin syndrome caused by ingestion of two different SSRIs

ANS: D The nurse should suspect that the client is suffering from serotonin syndrome possibly caused by ingesting two different SSRIs (Zoloft and Paxil). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.

During a smoking cessation group, the community health nurse explains that in their effort to quit smoking, a reciprocal inhibition approach will be used. The nurse should give the group which example of this technique? A. "Before you can smoke, you must first take a half-hour walk." B. "When you have the urge to smoke, imagine being short of breath." C. "You'll receive $1 for each cigarette not smoked and forfeit $2 for each cigarette smoked." D. "When you have the urge to smoke, hold your breath, then rhythmically breathe."

ANS: D These breathing exercises cannot be done while the client smokes. Therefore, they decrease or eliminate the undesired behavior (smoking) that is incompatible with the desired behavior (smoking cessation). This is an example of the behavior therapy of reciprocal inhibition.

A child always chooses to ask mother over father when seeking special privileges. The father is more apt to disagree than agree with the child's requests while the mother usually consents. The child's choice is the result of which component of operant conditioning? A. Conditioned stimuli B. Unconditioned stimuli C. Aversive stimuli D. Discriminative stimuli

ANS: D This child is able to discriminate between stimuli. This child can predict with assurance that asking mother (not father) will result in a desired response.

The nurse plans to confront a client about secondary gains related to extreme dependency on spouse. Which nursing statement would be most appropriate? A. "Do you believe dependency issues have been a lifelong concern for you?" B. "Have you noticed any anxiety during times when your husband makes decisions." C. "What do you know about individuals who depend on others for direction?" D. "How have the specifics of your relationship with your spouse benefited you?"

ANS: D When a client goes to excessive lengths to obtain nurturance and support from others, the client is seeking secondary gains. Secondary gains provide clients the support and attention that the client might not otherwise receive.

A client diagnosed with anorexia nervosa stopped eating 5 months ago and lost 25% of total body weight. Which subjective client response would the nurse assess to support this medical diagnosis? A. "I do not use any laxatives or diuretics to lose weight." B. "I am losing lots of hair. It's coming out in handfuls." C. "I know that I am thin, but I refuse to be fat!" D. "I don't know why people are worried. I need to lose this weight."

ANS: D When the client states, "I don't know why people are worried. I need to lose this weight," the client is exhibiting the subjective response of ineffective denial. This client is minimizing symptoms and is unable to admit impact of the disease on life patterns. The client does not perceive personal relevance of symptoms or danger.

What is the legal significance of a nurse's action when the nurse threatens a demanding client with restraints? A. The nurse can be charged with assault. B. The nurse can be charged with negligence. C. The nurse can be charged with malpractice. D. The nurse can be charged with beneficence.

ANS: A Assault is an act that results in a person's genuine fear and apprehension that he or she will be touched without consent.

A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin Decanoate) from a home health nurse. The client refuses medication at one regularly scheduled home visit. Which nursing intervention is ethically appropriate? A. Allow the client to decline the medication and document. B. Tell the client that if the medication is refused, hospitalization will occur. C. Arrange with a relative to add medication to the client's morning orange juice. D. Call for help to hold the client down while the injection is administered.

ANS: A It is ethically appropriate for the nurse to allow the client to decline the medication and provide accurate documentation. The client's right to refuse treatment should be upheld unless the refusal puts the client or others in harm's way.

An inpatient client, whom the treatment team has determined to be a danger to self, gives notice of intention to leave the hospital. What information should the nurse recognize as having an impact on the treatment team's next action? A. State law determines how long a psychiatric facility can hold a client. B. Federal law determines if the client is competent. C. The client's family involvement will determine if discharge is possible. D. Hospital policies will determine treatment team actions.

ANS: A Most states commonly cite that in an emergency a client who is dangerous to self or others may be involuntarily hospitalized.

A client is recovering from abdominal surgery. In order to maximize the learning process prior to discharge teaching, which assessment should be performed by the nurse? A. Assessing the client's level of pain B. Assessing and documenting the client's vital signs C. Assessing skin turgor and hydration status D. Assessing incisional site for serosanguineous drainage

ANS: A Pain will distract the client and interfere with the learning process.

The nurse should recognize which acronym as representing problem-oriented charting? A. SOAPIE B. APIE C. DAR D. PQRST

ANS: A The acronym SOAPIE represents problem-oriented charting which reflects the subjective, objective, assessment, plan, implementation, and evaluation format. This type of charting identifies nursing diagnoses (client problems) on a written plan of care with appropriate nursing interventions described for each.

A community health nurse is planning a health fair at a local shopping mall. Which middle-class socioeconomic cultural group should the nurse anticipate would most value preventive medicine and primary health care? A. Northern European Americans B. Native Americans C. Latino Americans D. African Americans

ANS: A The community health nurse should anticipate that Northern European Americans, especially those who achieve middle-class socioeconomic status, place the most value on preventative medicine and primary health care. This value is most likely related to this group's educational level and financial capability. Many members of the Native American, Latino American, and African American subgroups value folk medicine practices.

Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurse's coworker observes this action but does nothing for fear of repercussion. What is the ethical interpretation of the coworker's lack of involvement? A. Taking no action is still considered an unethical action by the coworker. B. Taking no action releases the coworker from ethical responsibility. C. Taking no action is advised when potential adverse consequences are foreseen. D. Taking no action is acceptable because the coworker is only a bystander.

ANS: A The coworker's lack of involvement can be interpreted as an unethical action. The coworker is experiencing an ethical dilemma in which a decision needs to be made between two unfavorable alternatives. The coworker has a responsibility to report any observed unethical actions.

After assertiveness training, a formerly passive client appropriately confronts a peer in group therapy. The group leader states, "I'm so proud of you for being assertive. You are so good!" Which communication technique has the leader employed? A. The nontherapeutic technique of giving approval B. The nontherapeutic technique of interpreting C. The therapeutic technique of presenting reality D. The therapeutic technique of making observations

ANS: A The group leader has employed the nontherapeutic technique of giving approval. Giving approval implies that the nurse has the right to pass judgment on whether the client's ideas or behaviors are "good" or "bad." This creates a conditional acceptance of the client.

A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations? A. Refusing to give any information to the caller, citing rules of confidentiality B. Refusing to give any information to the caller by hanging up C. Affirming that the person has been seen at the facility but providing no further information D. Suggesting that the caller speak to the client's therapist

ANS: A The most appropriate action by the nurse is to refuse to give any information to the caller. Admission to the facility would be considered protected health information (PHI) and should not be disclosed by the nurse without prior client consent.

A Native American client is admitted to an emergency department (ED) with an ulcerated toe secondary to uncontrolled diabetes mellitus. The client refuses to talk to a physician unless a shaman is present. Which nursing intervention is most appropriate? A. Try to locate a shaman that will agree to come to the ED. B. Explain to the client that "voodoo" medicine will not heal the ulcerated toe. C. Ask the client to explain what the shaman can do that the physician cannot. D. Inform the client that refusing treatment is a client's right.

ANS: A The most appropriate nursing intervention would be to try to locate a shaman who will agree to come to the ED. The nurse should understand that in the Native American culture, religion and health-care practices are often intertwined. The shaman, a medicine man, may confer with physicians regarding the care of a client. Research supports the importance of both health-care systems in the overall wellness of Native American clients.

A nurse is assessing a client diagnosed with schizophrenia for the presence of hallucinations. Which therapeutic communication technique used by the nurse is an example of making observations? A. "You appear to be talking to someone I do not see." B. "Please describe what you are seeing." C. "Why do you continually look in the corner of this room?" D. "If you hum a tune, the voices may not be so distracting."

ANS: A The nurse is making an observation when stating, "You appear to be talking to someone I do not see." Making observations involves verbalizing what is observed or perceived. This encourages the client to recognize specific behaviors and make comparisons with the nurse's perceptions.

Which therapeutic communication technique is being used in this nurse-client interaction? Client: "My father spanked me often." Nurse: "Your father was a harsh disciplinarian." A. Restatement B. Offering general leads C. Focusing D. Accepting

ANS: A The nurse is using the therapeutic communication technique of restatement. Restatement involves repeating the main idea of what the client has said. The nurse uses this technique to communicate that the client's statement has been heard and understood.

A Latin American man refuses to acknowledge responsibility for hitting his wife, stating instead, "It's the man's job to keep his wife in line." Which cultural belief should a nurse associate with this client's behavior? A. Families are male dominated with clear male-female role distinctions. B. Religious tenets support the use of violence in a marital context. C. The nuclear family is female dominated and the mother possesses ultimate authority. D. Marriage dynamics are controlled by dominant females in the family.

ANS: A The nurse should associate the cultural belief that families are male dominated with clear male-female role distinctions with the client's abusive behavior. The father in the Latin American family usually possesses the ultimate authority.

The following outcome was developed for a client: "Client will list five personal strengths by the end of day 1." Which correctly written nursing diagnostic statement most likely generated the development of this outcome? A. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements B. Self-care deficit R/T altered thought processes C. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10 D. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt

ANS: A The nurse should determine that altered self-esteem and self-deprecating statements would generate the outcome to list personal strengths by the end of day 1. Self-care deficit, disturbed body image, and risk for disturbed self-concept would generate specific outcomes in accordance with specific needs and goals. The self-care deficit and risk for disturbed self-concept nursing diagnoses are incorrectly written.

In what probable way should a nurse expect an Asian American client to view mental illness? A. Mental illness relates to uncontrolled behaviors that bring shame to the family. B. Mental illness is a curse from God related to immoral behaviors. C. Mental illness is cured by home remedies based on superstitions. D. Mental illness is cured by "hot and cold" herbal remedies.

ANS: A The nurse should expect that many Asian Americans are most likely to view mental illness as uncontrolled behavior that brings shame to the family. It is often more acceptable for mental distress to be expressed as physical ailments.

The following North American Nursing Diagnosis Association (NANDA) nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement? A. The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism. B. The client has a history of four suicide attempts in adolescence. C. The client expresses hopelessness and helplessness and isolates self. D. The client has disorganized thought processes and delusional thinking.

ANS: A The nurse should identify that a client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury due to confusion and potential for falls. History of suicide and hopelessness would lead to the development of a risk for suicide nursing diagnosis. Disorganized thoughts and delusional thinking would lead to the development of an altered thought process nursing diagnosis.

Which cultural considerations should a nurse identify with Western European Americans? A. They are present-time oriented and perceive the future as God's will. B. They value youth, and older adults are commonly placed in nursing homes. C. They are at high risk for alcoholism due to a genetic predisposition. D. They are future oriented and practice preventive health care.

ANS: A The nurse should identify that most Western European Americans are present oriented and perceive the future as God's will. Older adults are held in positions of respect and are often cared for in the home instead of nursing homes.

A client requests information on several medications in order to make an informed choice about management of depression. A nurse should provide this information to facilitate which ethical principle? A. Autonomy B. Beneficence C. Nonmaleficence D. Justice

ANS: A The nurse should provide the information to support the client's autonomy. A client who is capable of making independent choices should be permitted to do so. In instances when clients are incapable of making informed decisions, a legal guardian or representative would be asked to give consent.

During the first interview with a man from Syria who has just lost his son in a car accident, in sympathy for the man's loss, the female nurse reaches out and hugs him. Which is an accurate evaluation of the nurse's action? A. The nurse's action should be evaluated as unacceptable due to breech of cultural norms. B. The nurse's action should be evaluated as empathetic; encouraging expressions of feelings. C. The nurse's action should be evaluated as the technique of offering self. D. The nurse's action should be evaluated as inappropriate due to poor timing.

ANS: A The nurse's action should be evaluated as unacceptable due to breech of cultural norms. During communication, Arab Americans stand close together, maintain steady eye contact, and may touch the other's hand or shoulder but only between members of the same sex.

Which example of a therapeutic communication technique would be effective in the planning phase of the nursing process? A. "We've discussed past coping skills. Let's see if these coping skills can be effective now." B. "Please tell me in your own words what brought you to the hospital." C. "This new approach worked for you. Keep it up." D. "I notice that you seem to be responding to voices that I do not hear."

ANS: A This is an example of the therapeutic communication technique of formulating a plan of action. By the use of this technique, the nurse can help the client plan in advance to deal with a stressful situation which may prevent anger and/or anxiety from escalating to an unmanageable level.

A client is struggling to explore and solve a problem. Which nursing statement would verbalize the implication of the client's actions? A. "You seem to be motivated to change your behavior." B. "How will these changes affect your family relationships?" C. "Why don't you make a list of the behaviors you need to change." D. "The team recommends that you make only one behavioral change at a time."

ANS: A This is an example of the therapeutic communication technique of verbalizing the implied. Verbalizing the implied puts into words what the client has only implied or said indirectly.

During a nurse-client interaction, which nursing statement may belittle the client's feelings and concerns? A. "Don't worry. Everything will be alright." B. "You appear uptight." C. "I notice you have bitten your nails to the quick." D. "You are jumping to conclusions."

ANS: A This nursing statement is an example of the nontherapeutic communication block of belittling feelings. Belittling feelings occur when the nurse misjudges the degree of the client's discomfort, thus a lack of empathy and understanding may be conveyed.

Which nursing response is an example of the nontherapeutic communication block of requesting an explanation? A. "Can you tell me why you said that?" B. "Keep your chin up. I'll explain the procedure to you." C. "There is always an explanation for both good and bad behaviors." D. "Are you not understanding the explanation I provided?"

ANS: A This nursing statement is an example of the nontherapeutic communication block of requesting an explanation. Requesting an explanation is when the client is asked to provide the reason for thoughts, feelings, behaviors, and events. Asking "why" a client did something or feels a certain way can be very intimidating and implies that the client must defend his or her behavior or feelings.

A student nurse is learning about the appropriate use of touch when communicating with clients diagnosed with psychiatric disorders. Which statement by the instructor best provides information about this aspect of therapeutic communication? A. "Touch carries a different meaning for different individuals." B. "Touch is often used when deescalating volatile client situations." C. "Touch is used to convey interest and warmth." D. "Touch is best combined with empathy when dealing with anxious clients."

ANS: A Touch can elicit both negative and positive reactions, depending on the people involved and the circumstances of the interaction.

Which of the following individuals are communicating a message? (Select all that apply.) A. A mother spanking her son for playing with matches B. A teenage boy isolating himself and playing loud music C. A biker sporting an eagle tattoo on his biceps D. A teenage girl writing, "No one understands me" E. A father checking for new e-mail on a regular basis

ANS: A, B, C, D The nurse should determine that spanking, isolating, getting tattoos, and writing are all ways in which people communicate messages to others. It is estimated that about 70% to 90% of communication is nonverbal.

A female nurse is caring for an Arab American male client. When planning effective care for this client, the nurse should be aware of which of the following cultural considerations? (Select all that apply.) A. Limited touch is acceptable only between members of the same sex. B. Conversing individuals of this culture stand far apart and do not make eye contact. C. Devout Muslim men may not shake hands with women. D. The man is the head of the household and women take on a subordinate role. E. Men of this culture are responsible for the education of their children.

ANS: A, C, D When planning effective care for this client, the nurse should be aware that limited touch within this culture is acceptable only between members of the same sex, that devout Muslim men may not shake hands with women, and that women are subordinate to the man, who is the head of household. Conversing individuals of this culture stand close together and maintain eye contact. Arab American women are responsible for the education of the children.

A nurse is evaluating the effectiveness of teaching after instructing a group of clients on joint replacement. In the evaluation step of the nursing process, which learning domain is the most difficult to measure? A. Normative domain B. Affective domain C. Cognitive domain D. Psychomotor domain

ANS: B Affective knowledge is the most difficult to evaluate because of differences in values, cultures, and attitudes.

A nursing instructor is teaching about cultural characteristics. Which statement by the student indicates the need for further instruction? A. "All cultures communicate freely within their group." B. "All cultures embrace light therapeutic touch." C. "All cultures view the importance of timeliness differently." D. "All cultures display biological variations."

ANS: B All cultures do not embrace light therapeutic touch. In the Native American culture, if a hand is offered to another it may be accepted with a light touch; however, in the Asian culture, touching during communication has been historically considered unacceptable. This student statement indicates the need for further instruction.

In the situation presented, which nursing intervention constitutes false imprisonment? A. The client is combative and will not redirect stating, "No one can stop me from leaving." The nurse seeks the physician's order after the client is restrained. B. The client has been consistently seeking the attention of the nurse much of the day. The nurse institutes seclusion. C. A psychotic client, admitted in an involuntary status, runs off the psychiatric unit. The nurse runs after the client and the client agrees to return. D. A client hospitalized as an involuntary admission attempts to leave the unit. The nurse calls the security team and they prevent the client from leaving.

ANS: B False imprisonment is the deliberate and unauthorized commitment of a person within fixed limits by the use of verbal or physical means. Seclusion should only be used in an emergency situation to prevent harm after least restrictive means have been unsuccessfully attempted.

A student nurse tells the instructor, "I'm concerned that when a client asks me for advice I won't have a good solution." Which should be the nursing instructor's best response? A. "It's scary to feel put on the spot by a client. Nurses don't always have the answer." B. "Remember, clients, not nurses, are responsible for their own choices and decisions." C. "Just keep the client's best interests in mind and do the best that you can." D. "Set a goal to continue to work on this aspect of your practice."

ANS: B Giving advice tells the client what to do or how to behave. It implies that the nurse knows what is best and that the client is incapable of any self-direction. It discourages independent thinking.

The experience of being physically restrained can be traumatic. Which nursing intervention would best help the client deal with this experience? A. Administering a tranquilizing medication before applying the restraints B. Talking to the client at brief but regular intervals while the client is restrained C. Decreasing stimuli by leaving the client alone most of the time D. Checking on the client infrequently, in order to meet documentation requirements

ANS: B Restraints are never to be used as punishment or for the convenience of the staff. Connecting with the client by maintaining communication during the period of restraint will help the client recognize this intervention as a therapeutic treatment versus a punishment.

Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems? A. Medical history is of little significance and can be eliminated from the nursing assessment. B. Assessment provides a holistic view of the client including biopsychosocial aspects. C. Comprehensive assessments can be performed only by advanced practice nurses. D. Psychosocial evaluations are gained by subjective reports rather than objective observations.

ANS: B The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the client. A thorough assessment involves collecting and analyzing data from the client, significant others, and health-care providers that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities.

A mother rescues two of her four children from a house fire. In the emergency department, she cries, "I should have gone back in to get them. I should have died, not them." What is the nurse's best response? A. "The smoke was too thick. You couldn't have gone back in." B. "You're feeling guilty because you weren't able to save your children." C. "Focus on the fact that you could have lost all four of your children." D. "It's best if you try not to think about what happened. Try to move on."

ANS: B The best response by the nurse is, "You're experiencing feelings of guilt because you weren't able to save your children." This response utilizes the therapeutic communication technique of reflection which identifies a client's emotional response and reflects these feelings back to the client so that they may be recognized and accepted.

Which situation exemplifies both assault and battery? A. The nurse becomes angry, calls the client offensive names, and withholds treatment. B. The nurse threatens to "tie down" the client and then does so against the client's wishes. C. The nurse hides the client's clothes and medicates the client to prevent elopement. D. The nurse restrains the client without just cause and communicates this to family.

ANS: B The nurse in this situation has committed both assault and battery. Assault refers to an action that results in fear and apprehension that the person will be touched without consent. Battery is the touching of another person without consent.

When working with clients of a particular culture, which action should a nurse avoid? A. Maintaining eye contact based on cultural norms B. Assuming that all individuals who share a culture or ethnic group are similar C. Supporting the client in participating in cultural and spiritual rituals D. Using an interpreter to clarify communication

ANS: B The nurse should avoid assuming that all individuals who share a culture or ethnic group are similar. This action constitutes stereotyping and must be avoided. Within each culture, many variations and subcultures exist. Clients should be treated as individuals.

Which nursing diagnosis should a nurse identify as being correctly formulated? A. Schizophrenia R/T biochemical alterations AEB altered thought B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance C. Depressed mood R/T multiple life stressors D. Developmental disability R/T early-onset schizophrenia AEB hallucinations

ANS: B The nurse should determine that the correctly written diagnosis would be Self-care deficit: hygiene R/T altered thought AEB disheveled appearance. The nursing diagnosis should describe the client's condition, facilitating the choice of interventions.

An African American youth, growing up in an impoverished neighborhood, seeks affiliation with a black gang. Soon he is engaging in theft and assault. What cultural consideration should a nurse identify as playing a role in this youth's choices? A. Most African American homes are headed by strong, dominant father figures. B. Most African Americans choose to remain within their own social organization. C. Most African Americans are uncomfortable expressing emotions and need group affiliations. D. Most African Americans have limited religious beliefs which contribute to criminal activity.

ANS: B The nurse should identify that a tendency to remain within one's own social organization may have played a role in this youth's choice to join a black gang. African Americans who have assimilated into the dominant culture are likely to be well educated and future focused. Those who have not assimilated may be unemployed or have low-paying jobs, and view the future as hopeless given their previous encounters with racism and discrimination.

A nurse maintains an uncrossed arm and leg posture. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening? A. S B. O C. L D. E E. R

ANS: B The nurse should identify that maintaining an uncrossed arm and leg posture is nonverbal behavior that reflects the "O" in the active-listening acronym SOLER. The acronym SOLER includes sitting squarely facing the client (S), open posture when interacting with the client (O), leaning forward toward the client (L), establishing eye contact (E), and relaxing (R).

Which client should a nurse identify as a potential candidate for involuntary commitment? A. A client living under a bridge in a cardboard box B. A client threatening to commit suicide C. A client who never bathes and wears a wool hat in the summer D. A client who eats waste out of a garbage can

ANS: B The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatment is a danger to self and requires emergency treatment.

How should a nurse prioritize nursing diagnoses? A. By the established goal of care B. By the life-threatening potential C. By the physician's priority of care D. By the client's preference

ANS: B The nurse should prioritize nursing diagnoses related to life-threatening potential. Safety is always the nurse's first priority.

A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique used by the nurse is an example of a broad opening? A. "What occurred prior to the rape, and when did you go to the emergency department?" B. "What would you like to talk about?" C. "I notice you seem uncomfortable discussing this." D. "How can we help you feel safe during your stay here?"

ANS: B The nurse's statement, "What would you like to talk about?" is an example of the therapeutic communication technique of giving broad openings. Using a broad opening allows the client to take the initiative in introducing the topic and emphasizes the importance of the client's role in the interaction.

A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis accurately reflects this client's problem? A. Altered thought processes B. Altered sensory perception C. Anxiety D. Chronic confusion

ANS: B The nursing diagnosis altered sensory perception accurately reflects the client's symptoms of hearing things that others do not. A nursing diagnosis describes a client's condition and facilitates the prescription of interventions. Delusional thinking, confusion, and disorientation are problems associated with the nursing diagnosis of altered thought processes.

What is the purpose when a nurse gathers client information? A. It enables the nurse to modify client behaviors related to personality disorders. B. It enables the nurse to make sound clinical judgments and plan appropriate client care. C. It enables the nurse to prescribe the appropriate medications. D. It enables the nurse to assign the appropriate Axis I diagnosis.

ANS: B The purpose of gathering client information is to enable the nurse to make sound clinical judgments and plan appropriate care. The nurse should complete a thorough assessment of the client including information collected from the client, significant others, and health-care providers.

Group therapy is strongly encouraged, but not mandatory, on an inpatient psychiatric unit. The unit manager's policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager's policy preserve? A. Justice B. Autonomy C. Veracity D. Beneficence

ANS: B The unit manager's policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. The principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that health-care workers must respect these decisions.

After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, "You are incompetent!" Which is the nurse's best response? A. "Do you believe that I was the cause of your blood test being canceled?" B. "I see that you are upset, but I feel uncomfortable when you swear at me." C. "Have you ever thought about ways to express anger appropriately?" D. "I'll give you some space. Let me know if you need anything."

ANS: B This is an example of the appropriate use of feedback. Feedback should be directed toward behavior that the client has the capacity to modify.

Which therapeutic communication technique should the nurse use when communicating with a client who is experiencing auditory hallucinations? A. "My sister has the same diagnosis as you and she also hears voices." B. "I understand that the voices seem real to you, but I do not hear any voices." C. "Why not turn up the radio so that the voices are muted." D. "I wouldn't worry about these voices. The medication will make them disappear."

ANS: B This is an example of the therapeutic communication technique of presenting reality. Presenting reality is when the client has a misperception of the environment. The nurse defines reality or indicates his or her perception of the situation for the client.

A client slammed a door on the unit several times. The nurse responds, "You seem angry." The client states, "I'm not angry." What therapeutic communication technique has the nurse employed and what defense mechanism is the client unconsciously demonstrating? A. Making observations and the defense mechanism of suppression B. Verbalizing the implied and the defense mechanism of denial C. Reflection and the defense mechanism of projection D. Encouraging descriptions of perceptions and the defense mechanism of displacement

ANS: B This is an example of the therapeutic communication technique of verbalizing the implied. The nurse is putting into words what the client has only implied by words or actions. Denial is the refusal of the client to acknowledge the existence of a real situation, the feelings associated with it, or both.

To effectively care for Asian American clients, a nurse should be aware of which cultural norm? A. Obesity and alcoholism are common problems. B. Older people maintain positions of authority within the culture. C. "Tai" and "chi" are the fundamental concepts of Asian health practices. D. Asian Americans are likely to seek psychiatric help.

ANS: B To effectively care for clients of the Asian American culture, the nurse should be aware that older people in this culture maintain positions of authority. Obesity and alcoholism are low among Asian Americans. The balance of "yin" and "yang," not "tai" and "chi," is the fundamental concept of Asian health practices. In the Asian culture, psychiatric illness is often believed to be out-of-control behavior and would be considered shameful to individuals and families.

When interviewing a client of a different culture, which of the following questions should a nurse consider asking? (Select all that apply.) A. Would using perfume products be acceptable? B. Who may be expected to be present during the client interview? C. Should communication patterns be modified to accommodate this client? D. How much eye contact should be made with the client? E. Would hand shaking be acceptable?

ANS: B, C, D, E When interviewing a client from a different culture, the nurse should consider who might be with the client during the interview, modifications of communication patterns, amount of eye contact, and hand-shaking acceptability. Given that cultural influences affect human behavior, its interpretation, and another person's response, it is important for nurses to understand the effects of these cultural influences to work effectively with diverse populations.

Because of cultural characteristics, in which of the following cultural groups would a nurse's assessment of mood and affect be most challenging? (Select all that apply.) A. Arab Americans B. Native Americans C. Latino Americans D. Western European Americans E. Asian Americans

ANS: B, E The nurse should expect that both Native Americans and Asian Americans might be difficult to assess for mood and affect. In both cultures, expressing emotions is difficult. Native Americans are encouraged to not communicate private thoughts. Asian Americans may have a reserved public demeanor and may be perceived as shy or uninterested.

A client diagnosed with dependant personality disorder states, "Do you think I should move from my parent's house and get a job?" Which nursing response is most appropriate? A. "It would be best to do that in order to increase independence." B. "Why would you want to leave a secure home?" C. "Let's discuss and explore all of your options." D. "I'm afraid you would feel very guilty leaving your parents."

ANS: C The most appropriate response by the nurse is, "Let's discuss and explore all of your options." In this example, the nurse is encouraging the client to formulate ideas and decide independently the appropriate course of action.

The nursing staff is discussing the concept of competency. Which information about competency should a nurse recognize as true? A. Competency is determined with a client's compliance with treatment. B. Refusal of medication can initiate an incompetency hearing leading to forced medications. C. A competent client has the ability to make reasonable judgments and decisions. D. Competency is a medical determination made by the client's physician.

ANS: C A competent individual's cognition is not impaired to an extent that would interfere with decision making.

Which cultural group is correctly matched with the disease process for which this group is most susceptible? A. African Americans are susceptible to lactose intolerance. B. Western European Americans are susceptible to malaria. C. Arab Americans are susceptible to sickle cell disease. D. Jewish Americans are susceptible to thalassemia.

ANS: C A number of genetic diseases are more common in the Arab American population, including sickle cell disease, tuberculosis, malaria, trachoma, typhus, hepatitis, typhoid fever, dysentery, parasitic infestations, thalassemia, and cardiovascular disease.

A client is concerned that information given to the nurse remains confidential. Which is the nurse's best response? A. "Your information is confidential. It will be kept just between you and I." B. "I will share the information with staff members only with your approval." C. "If the information impacts your care, I will need to share it with the treatment team." D. "You can make the decision whether your physician needs this information or not."

ANS: C Basic to the psychiatric client's hospitalization is his or her right to confidentiality and privacy. When admitted to an inpatient psychiatric facility, a client gives implied consent for information to be shared with health-care workers specifically involved in the client's care.

A nurse is preparing to establish a therapeutic relationship with a grieving family from China. Which nursing intervention would be considered most appropriate? A. Touch each member lightly as this enhances the communication process. B. Direct questions to the young males of the family as they maintain positions of authority. C. Avoid direct eye contact as it implies rudeness. D. Remain objective and empathetic as Asians express feelings freely.

ANS: C In the Asian culture, eye contact is often avoided as it connotes rudeness and lack of respect.

A student nurse asks an instructor how best to develop nursing outcomes for clients. Which reply by the instructor most accurately answers the student's question? A. "Use the Nursing Interventions Classification (NIC) as a reference for nursing outcomes." B. "Look at your client's problems and set a realistic, achievable goal." C. "Use the Nursing Outcomes Classification (NOC) as a reference for nursing outcomes." D. "Copy your standard outcomes from a nursing care plan textbook."

ANS: C NOC is a comprehensive, standardized classification of client outcomes developed to evaluate the effects of nursing interventions.

There is one bed available on an inpatient psychiatric unit. For which client should a nurse advocate emergency commitment? A. An individual who is persistently mentally ill and evicted from an apartment B. An individual treated in the emergency department (ED) for generalized anxiety disorder C. An individual who is delusional and has a plan to kill his wife D. An individual who rates mood 4/10 and is participating in a no-harm safety plan

ANS: C The criteria for involuntary emergency commitment include danger to self and/or others. Of the four clients considered, the client who is delusional and has a plan to kill his wife meets this criterion as a danger to others.

An instructor is correcting a nursing student's clinical worksheet. Which instructor statement is the best example of effective feedback? A. "Why did you use the client's name on your clinical worksheet?" B. "You were very careless to refer to your client by name on your clinical worksheet." C. "Surely you didn't do this deliberately, but you breeched confidentiality by using the client's name." D. "It is disappointing that after being told, you're still using client names on your worksheet."

ANS: C The instructor's statement, "Surely you didn't do this deliberately, but you breeched confidentiality by using the client's name." is an example of effective feedback. Feedback is a method of communication to help others consider a modification of behavior. Feedback should be descriptive, specific, and directed toward a behavior that the person has the capacity to modify and should impart information rather than offer advice or criticize the individual.

A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse? A. Health teacher B. Case manager C. Milieu manager D. Psychotherapist

ANS: C The milieu manager implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. Health teaching involves promoting health and a safe environment. Case management is utilized to organize client care so that outcomes are achieved. Psychotherapy involves conducting individual, couples, group, and family counseling.

Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I am anxious, the only thing that calms me down is alcohol." Nurse: "Other than drinking, what alternatives have you explored to decrease anxiety?" A. Reflecting B. Making observations C. Formulating a plan of action D. Giving recognition

ANS: C The nurse is using the therapeutic communication technique of formulating a plan of action to help the client explore alternatives to drinking alcohol. The use of this technique, rather than direct confrontation regarding the client's poor coping choice, may serve to prevent anger or anxiety from escalating.

A nursing instructor is presenting content on the provisions of the nurse practice act as it relates to their state. Which student statement indicates a need for further instruction? A. "The nurse practice act provides a list of definitions of important terms including the definition of nursing." B. "The nurse practice act lists education requirements for licensure and reciprocity." C. "The nurse practice act contains detailed statements that describe the scope of practice for registered nurses (RNs)." D. "The nurse practice act lists the general authority and powers of the state board of nursing."

ANS: C The nurse practice act contains broad, not detailed, statements that describe the scope of practice for various levels of nursing (APN, RN, LPN), not just for the RN. This student statement indicates a need for further instruction.

Which data gathering technique is employed during the assessment phase of the nursing process? A. Asking the client to rate mood after administering an antidepressant B. Asking the client to verbalize understanding of previously explained unit rules C. Asking the client to describe any thoughts of self-harm D. Asking the client if the group on assertiveness skills was helpful

ANS: C The nurse should ask the client to describe any thoughts of self-harm during the assessment phase of the nursing process. Assessment involves collecting and analyzing data about the client that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities. The other three options are employed during the evaluation phase of the nursing process.

What is being assessed when a nurse asks a client to identify name, date, residential address, and situation? A. Mood B. Perception C. Orientation D. Affect

ANS: C The nurse should ask the client to identify name, date, residential address, and situation to assess the client's orientation. Assessment of the client's orientation to reality is part of a mental status evaluation.

Northern European Americans value punctuality, hard work, and the acquisition of material possessions and status. A nurse should recognize that these values may contribute to which form of psychopathology? A. Dissociative disorders B. Alzheimer's dementia C. Stress-related disorders D. Schizophrenia-spectrum disorders

ANS: C The nurse should correlate Northern European American values, such as punctuality, hard work, and acquisition of material possessions, with stress-related disorders. Psychopathology may occur when individuals fail to meet the expectations of the culture.

A Latin American woman refuses to participate in an assertiveness training group. Which cultural belief should a nurse identify as most likely to have influenced this client's decision? A. Future orientation causes the client to devalue assertiveness skills. B. Decreased emotional expression makes it difficult to be assertive. C. Assertiveness techniques may not be aligned with the client's definition of the female role. D. Religious prohibitions prevent the client's participation in assertiveness training.

ANS: C The nurse should identify that the Latin American woman's refusal to participate in an assertiveness training group may be influenced by the Latin American cultural definition of the female role. Latin Americans place a high value on the family which is male dominated. The father usually possesses the ultimate authority.

A nurse should recognize that clients who have a history of missed or late medical appointments are most likely to come from which cultural group? A. African Americans B. Asian Americans C. Native Americans D. Jewish Americans

ANS: C The nurse should recognize that Native American clients might have a history of missed or late medical appointments. Many Native Americans are not ruled by the clock. The concept of time is casual and focused on the present.

A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the client's wishes? A. When the client makes inappropriate sexual innuendos to a staff member B. When the client constantly demands inappropriate attention from the nurse C. When the client physically attacks another client after being confronted in group therapy D. When the client refuses to bathe or perform hygienic activities

ANS: C The nurse would have the right to medicate a client against his or her wishes if the client physically attacks another client. This client poses a significant risk to safety and is incapable of making rational choices. The client's refusal to accept treatment can be challenged because the client is endangering the safety of others.

The nurse is interviewing a newly admitted psychiatric client. Which nursing statement is an example of offering a "general lead"? A. "Do you know why you are here?" B. "Are you feeling depressed or anxious?" C. "Yes, I see. Go on." D. "Can you chronologically order the events that led to your admission?"

ANS: C The nurse's statement, "Yes, I see. Go on." is an example of the therapeutic communication technique of a general lead. Offering a general lead encourages the client to continue sharing information.

A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings, difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate outcome for this client's problem? A. The client will avoid daytime napping and attend all groups. B. The client will exercise, as needed, before bedtime. C. The client will sleep 7 uninterrupted hours by day four of hospitalization. D. The client's sleep habits will improve during hospitalization.

ANS: C The outcome "The client will sleep 7 uninterrupted hours by day four of hospitalization." is accurately written and an appropriate outcome to address the client problem of insomnia. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes.

The nurse asks a newly admitted client, "What can we do to help you?" What is the purpose of this therapeutic communication technique? A. To reframe the client's thoughts about mental health treatment B. To put the client at ease C. To explore a subject, idea, experience, or relationship D. To communicate that the nurse is listening to the conversation

ANS: C This is an example of the therapeutic communication technique of exploring. The purpose of using exploring is to delve further into the subject, idea, experience, or relationship. This technique is especially helpful with clients who tend to remain on a superficial level of communication.

Which nursing statement is a good example of the therapeutic communication technique of giving recognition? A. "You did not attend group today. Can we talk about that?" B. "I'll sit with you until it is time for your family session." C. "I notice you are wearing a new dress and you have washed your hair." D. "I'm happy that you are now taking your medications. They will really help."

ANS: C This is an example of the therapeutic communication technique of giving recognition. Giving recognition acknowledges and indicates awareness. This technique is more appropriate than complimenting the client which reflects the nurse's judgment.

A client on an inpatient psychiatric unit tells the nurse, "I should have died because I am totally worthless." In order to encourage the client to continue talking about feelings, which should be the nurse's initial response? A. "How would your family feel if you died?" B. "You feel worthless now, but that can change with time." C. "You've been feeling sad and alone for some time now?" D. "It is great that you have come in for help."

ANS: C This nursing statement is an example of the therapeutic communication technique of reflection. When reflection is used, questions and feelings are referred back to the client so that they may be recognized and accepted.

When interviewing a client, which nonverbal behavior should a nurse employ? A. Maintaining indirect eye contact with the client B. Providing space by leaning back away from the client C. Sitting squarely, facing the client D. Maintaining open posture with arms and legs crossed

ANS: C When interviewing a client, the nurse should employ the nonverbal behavior of sitting squarely, facing the client. Facilitative skills for active listening can be identified by the acronym SOLER. SOLER includes sitting squarely facing the client (S), open posture when interacting with a client (O), leaning forward toward the client (L), establishing eye contact (E), and relaxing (R).

Which is an accurate description of a common law? A. A common law would be invoked to deal with a nurse who, without justification, threatens a client with restraints. B. A common law would be invoked to deal with a nurse who touches a client without the client's consent. C. A common law would be invoked to deal with a hospital employee who steals drugs, hospital equipment, or both. D. A common law would be invoked to deal with a nurse's refusal to provide care for a specific client.

ANS: D Common laws apply to a body of principles that evolve from court decisions resolving various controversies. Common law may vary from state to state. Assault (threats) and battery (touch) are governed by civil law. Stealing is governed by criminal law.

An involuntarily committed client is verbally abusive to the staff and repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit? A. Verbally redirect the client, and then limit one-on-one interaction. B. Involve the hospital's security division as soon as possible. C. Notify the client that documenting personal staff information is against hospital policy. D. Continue professional attempts to establish a positive working relationship with the client.

ANS: D The most appropriate nursing action is to continue professional attempts to establish a positive working relationship with the client. The involuntarily committed client should be respected and has the right to assert grievances if rights are infringed.

A newly admitted client diagnosed with obsessive-compulsive disorder (OCD) washes hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation? A. "Everyone diagnosed with OCD needs to control their ritualistic behaviors." B. "It is important for you to discontinue these ritualistic behaviors." C. "Why are you asking for help if you won't participate in unit therapy?" D. "Let's figure out a way for you to attend unit activities and still wash your hands."

ANS: D The most appropriate statement by the nurse is, "Let's figure out a way for you to attend unit activities and still wash your hands." This statement reflects the therapeutic communication technique of formulating a plan of action. The nurse attempts to work with the client to develop a plan without damaging the therapeutic relationship or increasing the client's anxiety.

Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I get angry, I get into a fistfight with my wife or I take it out on the kids." Nurse: "I notice that you are smiling as you talk about this physical violence." A. Encouraging comparison B. Exploring C. Formulating a plan of action D. Making observations

ANS: D The nurse is using the therapeutic communication technique of making observations when noting that the client smiles when talking about physical violence. The technique of making observations encourages the client to compare personal perceptions with those of the nurse.

An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which violation of an ethical principle should a nurse recognize in this situation? A. Autonomy B. Beneficence C. Nonmaleficence D. Justice

ANS: D The nurse should determine that the ethical principle of justice has been violated by the physician's actions. The principle of justice requires that individuals should be treated equally regardless of race, sex, marital status, medical diagnosis, social standing, economic level, or religious belief.

Which statement should a nurse identify as correct regarding a client's right to refuse treatment? A. Clients can refuse pharmacological but not psychological treatment. B. Clients can refuse any treatment at any time. C. Clients can refuse only electroconvulsive therapy (ECT). D. Professionals can override treatment refusal if the client is actively suicidal or homicidal.

ANS: D The nurse should understand that health-care professionals can override treatment refusal when a client is actively suicidal or homicidal. A suicidal or homicidal client who refuses treatment may be a danger to self or others. This situation should be treated as an emergency, and treatment may be performed without informed consent.

When planning client care for a Latino American, the nurse should be aware of which cultural influence that may impact access to health care? A. The root doctor may be the first contact made when illness is encountered. B. The "yin" and "yang" practitioner may be the first contact made when illness is encountered. C. The shaman may be the first contact made when illness is encountered. D. The curandero may be the first contact made when illness is encountered.

ANS: D The nurse should understand that some Latin Americans may initially contact a curandero when illness is encountered. The curandero is the folk healer who is believed to have a gift from God for healing the sick. Treatments often include supernatural rituals, prayers, magic, practical advice, and indigenous herbs.

A nurse states to a client, "Things will look better tomorrow after a good night's sleep." This is an example of which communication technique? A. The therapeutic technique of "giving advice" B. The therapeutic technique of "defending" C. The nontherapeutic technique of "presenting reality" D. The nontherapeutic technique of "giving false reassurance"

ANS: D The nurse's statement, "Things will look better tomorrow after a good night's sleep." is an example of the nontherapeutic technique of giving false reassurance. Giving false reassurance indicates to the client that there is no cause for anxiety, thereby devaluing the client's feelings.

Which rationale by a nursing instructor best explains why it is challenging to globally classify the Asian American culture? A. Extremes of emotional expression prevent accurate assessment of this culture. B. Suspicion of Western civilization has resulted in minimal cultural research. C. The small size of this subpopulation makes research virtually impossible. D. The Asian American culture includes individuals from many different countries.

ANS: D The nursing instructor's best explanation is that the Asian American culture is difficult to classify globally due to the number of countries that identify with this culture. The Asian American culture includes peoples and descendents from Japan, China, Vietnam, the Philippines, Thailand, Cambodia, Korea, Laos, India, and the Pacific Islands. Within this culture there are vast differences in values, religious practices, languages, and attitudes.

Which expected client outcome should a nurse identify as being correctly formulated? A. Client will feel happier by discharge. B. Client will demonstrate two relaxation techniques. C. Client will verbalize triggers to anger by end of session. D. Client will initiate interaction with one peer during free time within 2 days.

ANS: D The statement "Client will initiate interaction with one peer during free time within 2 days." is an example of a correctly formulated expected outcome. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes.

A client states, "You won't believe what my husband said to me during visiting hours. He has no right treating me that way." Which nursing response would best assess the situation that occurred? A. "Does your husband treat you like this very often?" B. "What do you think is your role in this relationship?" C. "Why do you think he behaved like that?" D. "Describe what happened during your time with your husband."

ANS: D This is an example of the therapeutic communication technique of exploring. The purpose of using exploring is to delve further into the subject, idea, experience, or relationship. This technique is especially helpful with clients who tend to remain on a superficial level of communication.

Which nursing statement is a good example of the therapeutic communication technique of focusing? A. "Describe one of the best things that happened to you this week." B. "I'm having a difficult time understanding what you mean." C. "Your counseling session is in 30 minutes. I'll stay with you until then." D. "You mentioned your relationship with your father. Let's discuss that further."

ANS: D This is an example of the therapeutic communication technique of focusing. Focusing takes notice of a single idea or even a single word and works especially well with a client who is moving rapidly from one thought to another.

A client tells the nurse, "I feel bad because my mother does not want me to return home after I leave the hospital." Which nursing response is therapeutic? A. "It's quite common for clients to feel that way after a lengthy hospitalization." B. "Why don't you talk to your mother? You may find out she doesn't feel that way." C. "Your mother seems like an understanding person. I'll help you approach her." D. "You feel that your mother does not want you to come back home?"

ANS: D This is an example of the therapeutic communication technique of restatement. Restatement is the repeating of the main idea that the client has verbalized. This lets the client know whether or not an expressed statement has been understood and gives him or her the chance to continue, or clarify if necessary.