Mental Health Final
The family members of a client with early-stage Alzheimer's disease cannot provide adequate supervision for the client. What would be a reasonable alternative for the nurse to explore with them to meet their current needs? Long-term institutionalization Day care Group home residency Acute care hospitalization
Day care
When preparing educational materials for the family of a client diagnosed with progressive dementia, the nurse should include information related to which local resources? (Select all that apply.) Day care centers Family support groups Legal professionals Professional counseling Home health services
Day care centers Family support groups Professional counseling Home health services
A client on one-to-one supervision at arm's length indicates a need to go to the bathroom but reports, "I cannot 'go' with you standing there." How should the nurse respond to the client's concern? "For your safety I can be no more than an arm's length away." Leave the client's room and wait outside in the hall. "I understand" and allow the client to Keep the door open, but step to the side out of the client's view.
"For your safety I can be no more than an arm's length away."
Which question asked by the nurse demonstrates attention to the primary concern of palliative care? "Do you have a spiritual provider you want me to be contacted?" "Has your pain medication been effective at keeping you comfortable"? "Who will be your acting as your primary care provider?" "Do you want to receive your palliative care at home or in an institutional setting?"
"Has your pain medication been effective at keeping you comfortable"?
A client reports symptomatology that supports the diagnosis of sleep paralysis. The nurse effectively assesses the client by asking which question? "Is it difficult for you to fall asleep?" "Do you have a history of obsessive-compulsive behavior?" "Do you ever have nightmares?" "Have you ever fallen asleep while driving?"
"Have you ever fallen asleep while driving?"
To assess the client's perception of the event precipitating a crisis, the nurse would initially ask which question? "Who is available to help you?" "How does this situation affect your life?" "During difficult times in the past, what has helped you?" "Can you give me the name of someone you trust?"
"How does this situation affect your life?"
The nurse appropriately assesses an obese, hypertensive, Type 2 diabetic client when asking which question? "Is getting to sleep a problem for you?" Do you snooze when you sleep?" "How much sleep do you usually get each night?" "Do you regularly have nightmares?"
"How much sleep do you usually get each night?"
Which statement by a young client diagnosed with a severe and persistent mental illness would alert the nurse to the need for psychoeducational intervention? "I am looking for a job washing dishes at a diner." "I hear that marijuana helps calm you down." "I hate having my thoughts so messed up all the time." "I like to watch cartoons every morning."
"I hear that marijuana helps calm you down."
A client diagnosed with obsessive-compulsive personality disorder takes the nurse aside and mentions, "I've observed you interacting with that new patient. You are not approaching him properly. You should be more forceful with him." What response should the nurse provide to address the client's comment? A. "I will be continuing to follow the established care plan for the patient." B. "Your eye for perfection extends even to my nursing interventions." C. "I see you are trying to control that patient's therapy as well as your own." D. "That patient's care is really of no concern to you or to other clients."
"I will be continuing to follow the established care plan for the patient."
A client is brought to the hospital by an adult daughter, who visited this morning and found her parent to be confused and disoriented. When the client is admitted, the daughter states, "I'll take these glasses and hearing aid home, so they don't get lost." What is the nurse's best reply? "Because we do not have a copy of durable power of attorney, we cannot release them to you." "Don't worry. You can leave them at the bedside. We are insured for losses of this sort." "I would like to have your parent wear them. It will help there to be less confusion or retain more orientation." "That will be fine. I'll have you sign our hospital release form."
"I would like to have your parent wear them. It will help there to be less confusion or retain more orientation."
One criterion for the diagnosis of primary insomnia is met when the client makes which statement? "I was diagnosed with depression 2 months ago." "I have these terrible nightmares when I fall asleep." "I've actually missed work because I'm too tired to go." "I've had problems falling asleep for 3 weeks now."
"I've actually missed work because I'm too tired to go."
Which statement made by a parent of a child diagnosed with Tourette's syndrome would be assessed as a risk factor for family violence? "My husband lost his job, and it seems all our savings are going to pay for our son's expensive medication and all the other things he needs." "We have become active in the support group but still find the suggestions extremely difficult to put into practice." "Our son is really a good little boy, but he needs to be disciplined both at home and in school." "We shouldn't be, but we are ashamed of our son's disorder and his inability to control the tics in public."
"My husband lost his job, and it seems all our savings are going to pay for our son's expensive medication and all the other things he needs."
When the nurse finishes addressing a group of college women about rape, the following comments are heard during the discussion period. Which comment calls for additional teaching by the nurse? "I always thought rapes happened at night, but now I know that isn't true." "It makes sense that rape is a crime of violence, not a crime of sex." "So if you dress conservatively, your risk of being raped is small." "Who would have guessed that most rape victims know the rapist?"
"So if you dress conservatively, your risk of being raped is small."
A sexual assault survivor tells the nurse, "I should have tried to fight him off! But I was so terrified that I could not move. I should have tried harder." Which response should the nurse make to reassure the client? "Try not to think about it. Put it out of your mind." "The way you behaved was the right thing to do at the time." "Do you think others will think badly of you for not trying to fight?" "We each behave in characteristic ways in a crisis. That was your way.
"The way you behaved was the right thing to do at the time."
A woman comes to the crisis intervention clinic and reports that her 16-year-old son uses drugs in the home and often assaults her. What is the nurse's best response? "This is not an uncommon problem. Don't worry." "I have friends in law enforcement who can help us choose a solution." "Now that you are asking for help, everything will be all right." "Together we will be able to work on this problem."
"Together we will be able to work on this problem."
A cognitively impaired resident living at a long-term care unit has become unsteady when walking alone. The family is concerned about the potential for serious injury from falls and suggests that restraints be used. What is the nurse's best response to the family's request? "Using restraints puts the resident at higher risk for serious injury, even death." "You will need to make your request to the physician at the planning meeting." "Immobilization will cause constipation and necessitates the use of enemas." "The federal government forbids the use of restraints on elderly residents."
"Using restraints puts the resident at higher risk for serious injury, even death."
Which remark would signal to the nurse that there is a teaching need for the family of a client diagnosed with schizophrenia? "We always reprimand him whenever his behavior is bothersome." "We watch him closely for signs of illness associated with relapse." "We give positive recognition to him whenever he does even simple things well." "We have taught him to use the bus so we do not have to drive him everywhere."
"We always reprimand him whenever his behavior is bothersome."
During the immediate post-rape period what verbal nursing intervention would best lower client anxiety and increase feelings of well-being? "You are safe here. I will stay with you while you have your examination." "When you leave you will be given follow-up appointments for pregnancy and sexually transmitted disease screening." "I know you feel confused. We will make all the necessary decisions for you." "Please tell me as much about the details of the rape as you can remember."
"You are safe here. I will stay with you while you have your examination."
Which child is demonstrating behaviors that support a diagnosis of adolescent onset conduct disorder? A 12-year-old male who steals a bicycle as a gang initiation A 9-year-old male who smokes half a pack of cigarettes a day A 12-year-old female who regularly bullies her younger siblings A 9-year-old female who engages in sexually provocative behaviors
A 12-year-old male who steals a bicycle as a gang initiation
Which child is at lowest risk for abuse? A 5-year-old who has ADHD and a father who was abused as a child A 3-month-old who has colic and teenaged parents A 2-year-old who has leukemia and two working parents A 4-Year-Old who has cerebral palsy and cognitively challenged parents
A 2-year-old who has leukemia and two working parents
An expert witness is recognized by the court as having what characteristic? A thorough knowledge of the laws and rules that the defense uses to provide evidence to the court Law enforcement knowledge sufficient to be a consultant to a defense attorney A higher level of skill or expertise in a designated area Evidence of a crime having been committed
A higher level of skill or expertise in a designated area
A 12-year-old finds herself feeling anxious and overwhelmed and seeks out the school nurse to report that "Everything is changing; my body, the way the boys who were my friends are treating me, everything is so different." What term is used to describe what this child is experiencing? A maturational crisis A personal identity disorder Suicidal ideations Mild neurosis
A maturational crisis
A client with a history of repeated suicidal attempts refuses to participate in a no-suicide contract. What intensity of nursing observation should be instituted? A. Constant 24-hour, one-to-one observation at arm's length B. Every 15-minute observation around the clock C. One-to-one observation while client is awake D. Seclusion with 15-minute observation
A. Constant 24-hour, one-to-one observation at arm's length
A client tells the nurse that he believes his situation is intolerable and is observed isolating socially. Which nursing diagnosis should be considered? A. Hopelessness B. Chronic low self-esteem C. Compromised family coping D. Deficient knowledge
A. Hopelessness
A client diagnosed with osteoarthritis says she is unable to sleep because of aching in her hips and shoulders. Which medication would be appropriate in this situation? Aspirin Acetaminophen A sedative-hypnotic Meperidine
Acetaminophen
The nurse caring for a client diagnosed with Alzheimer's disease can anticipate that the family will need information about which medication therapy? Antihypertensives Immunosuppressants Benzodiazepines Acetylcholinesterase inhibitors
Acetylcholinesterase inhibitors
Which nursing intervention is best directed at the psychological needs of a physically abused client? Provide a referral to social services for economic problems. Facilitate contact with law enforcement to take legal action. Encourage the client to immediately leave the abuser Affirm that the client did not deserve or cause the abuse.
Affirm that the client did not deserve or cause the abuse.
A family member reports that the client had been oriented and able to carry on a logical conversation last evening, but this morning is confused and disoriented. The nurse can suspect that the client is displaying symptoms associated with which cognitive disorder? Selective inattention Dementia Amnesic disorder Delirium
Delirium
An older adult client tells the nurse that he prefers not to attend senior citizens meetings because "they are all old fuddy duddies who talk subjects to death but never take action." The nurse can hypothesize that the client is demonstrating which type of reaction? Ageism Projection of personal weaknesses Poor social skills Paranoid thinking
Ageism
Which behavior demonstrated by a woman attempting to escape a chronically abusive relationship presents the greatest personal risk? Adapting an aggressive attitude toward her abuser Relying on alcohol to escape the emotional pain of abuse Considering ways to commit suicide Threatening to call the police if she is abused again
Considering ways to commit suicide
The primary healthcare provider mentions to the nurse that a client who is about to be admitted has "sundowning." The nurse can expect to assess for which nightly behavior? Lethargy Agitation Depression Mania
Agitation
A client who has been prescribed an antipsychotic medication comes to the clinic 3 days after a scheduled visit and demonstrates evidence of restlessness and agitation. He states, "My medicine ran out, and I didn't remember where to get more." The client's case manager should initially implement which intervention to support medication adherence? Arrange to have the client's nursing care plan reflect the need for a medication change Arrange for a dose of the client's medication immediately. Arrange for the client to get to the nearest emergency department for treatment. Arrange for the client to see his psychiatrist as soon as the psychiatrist has an open appointment.
Arrange for a dose of the client's medication immediately.
What is the priority nursing intervention for a client diagnosed with borderline personality disorder? A. Respect the client's need for attention. B. Assess for suicidal and self-mutilating behaviors. C. Provide clear, consistent limits and boundaries. D. Protect other clients from manipulation.
Assess for suicidal and self-mutilating behaviors
A client with paraphilia tendencies tells the nurse that "I'm disgusted with my lifestyle." What is the nurse's initial intervention? Telling the client that the first step to managing this behavior is recognizing it as unhealthy. Recommending inpatient behavioral modification therapy. Assuring the client that this condition responds well to treatment. Assessing the client for the existence of suicidal ideations.
Assessing the client for the existence of suicidal ideations.
When the nurse believes the cycle of abuse is escalating and that a woman may be in severe physical danger, what should the priority nursing intervention be? Advising her to enter counseling at the mental health center Suggesting that she leave the abuser immediately and go to a trusted friend's home Assisting her in developing a plan to go to a shelter in case of a crisis Teaching her to counter verbal abuse with assertive replies
Assisting her in developing a plan to go to a shelter in case of a crisis
Which intervention demonstrates the fulfillment of a moral duty a nurse has to a dying patient? Advocating for the client's right to privacy Treating the client respectfully Assisting the client in determining their preferences and goals for care Assuring the client has the information needed for informed consent
Assisting the client in determining their preferences and goals for care
The goal of a nurse working in psychiatric rehabilitation would be to help clients in the community achieve which outcome? Cope more effectively with their symptoms Learn to live with dependency Complete mental health Live comfortably in a psychiatric treatment facility
Cope more effectively with their symptoms
To best assure the safety of a 3-year-old child whose parent admits to finding it difficult to control his/her anger, what is the most appropriate short-term goal for the parent? Stating a willingness to attend a support group for physical abusers within 1 week Demonstrating understanding of the impact of violence on the child within 2 days Showing remorse for their anger management issues within 2 days Beginning attending anger management training sessions within 2 weeks
Beginning attending anger management training sessions within 2 weeks
Unit practice requires inspection of all items being brought onto the unit by visitors. How can this be most effectively done? A. Asking clients to give staff any unsafe item that might have been left by a visitor. B. Having a staff member make frequent rounds during visiting hours to inspect gifts. C. Having a staff member sit at the door and check packages as visitors enter. D. Asking all visitors to report to the nurse's station before visiting a client.
C. Having a staff member sit at the door and check packages as visitors enter.
The nurse is preparing to set goals for a 10-year-old diagnosed with an impulse control disorder. To best ensure the expected therapeutic outcomes, the nurse includes goals that focus on what client need? Simple and easily defined Client centered and includes the client's input Age appropriate and achievable in a short period of time Family centered and long term in nature
Client centered and includes the client's input
Which nursing function is within the scope of practice for a psychiatric correctional nurse? (Select all that apply.) Completing a suicide assessment Treating inmates and establishing a therapeutic nurse-patient relationship Providing nursing care to meet both physical and mental needs of inmates Monitoring for exacerbation of mental health-related signs and symptoms. Evaluating sanity and competency of a perpetrator before a trial
Completing a suicide assessment Treating inmates and establishing a therapeutic nurse-patient relationship Providing nursing care to meet both physical and mental needs of inmates Monitoring for exacerbation of mental health-related signs and symptoms.
The mother of a 6-year-old child expresses concern over the child's frequent temper outbursts. He deals with any frustration by bullying and hitting and seldom shows any remorse for his actions. The nurse who gathers this data will note that the child's behaviors are most consistent with which diagnosis? Oppositional defiant disorder Conduct disorder Social phobia Attention deficit hyperactivity disorder (ADHD)
Conduct disorder
The nursing diagnosis Risk for self-directed violence has been added to the care plan of a suicidal client. Which is the most appropriate short-term goal for this diagnosis? A. Consistently participate in a self-help group. B. Will reclaim any prized possessions that were given away. C. Be able to name three personal strengths D. Seek help when feeling self-destructive.
D. Seek help when feeling self-destructive.
A client diagnosed with severe and persistent paranoid schizophrenia is accused of killing a homeless man when his auditory hallucinations commanded him to do so. What is the purpose of a psychiatric examination in this case? Suggest that hospitalization is preferable to incarceration Determine competence to stand trial The risk that violent client behavior is likely to reoccur Determine guilt
Determine competence to stand trial
A client has been diagnosed with gender identity disorder. The nurse can expect that the client will evidence which characteristic? Intense sexual urges focused on an object Discomfort with biological gender Inability to maintain sexual arousal Self-humiliation during the sexual act
Discomfort with biological gender
The nurse is expected to perform an assessment of a client suspected to be in the earliest stage of Alzheimer's disease. What finding would be out of character for the client who truly has early stage Alzheimer's disease? Confabulation to compensate for forgotten information Charming behavior designed to hide memory deficit Avoidance of questions by subject changing Easily frustrated by cognitive losses
Easily frustrated by cognitive losses
A 4-year-old child tells the nurse, "I'm a bad boy. Daddy always says I'm not worth a second look." This situation can be an example of which form of abuse? Emotional Physical Tough love Neglect
Emotional
Which skill is central to the role of all forensic nurses? Acting as a correctional mental health nurse Evidence collection that preserves the integrity of the evidence Creating therapeutic nurse-patient relationships with incompetent criminals Helping court-appointed lawyers with the suspect's testimony
Evidence collection that preserves the integrity of the evidence
A client diagnosed with conduct disorder craves what experience? Material possessions but lacks focus and direction Control of situations and constantly strategizes for such power Excitement without concern for possible negative outcomes Friendship but from those older than themselves
Excitement without concern for possible negative outcomes
The client who will most likely respond well to drug therapy for the management of compulsive deviant sexual behavior is one with which diagnosis? Antisocial personality disorder Exhibitionism Fetishism Low sexual drive
Exhibitionism
Which roles are considered a responsibility of a psychiatric forensic nurse? (Select all that apply.) Expert witness Consultant to law enforcement Direct care to inmates Competency therapist Forensic examiner
Expert witness Consultant to law enforcement Competency therapist Forensic examiner
An abuse victim tearfully tells the nurse in the emergency department, "Don't tell my husband that you know he beats me because if he thinks anyone knows, he will beat me again." Based on this information, what is the most appropriate nursing diagnosis? Hopelessness Risk for self-directed violence Post-trauma syndrome Fear
Fear
When providing possible interventions to promote the safety of a client reporting symptoms of somnambulism, the nurse should include which intervention? Regular bedtime dose of a benzodiazepine Avoiding the use of serotonergic medications Gating the stairways Sleeping on a mattress placed on the floor
Gating the stairways
Which characteristic places the client at highest risk for violence directed at others? Has delusions of persecution Has a history of recurrent severe depression Is in an alcohol rehabilitation program Is experiencing somatic symptoms for which no organic basis is found
Has delusions of persecution
An elderly woman who has been abused by her caregiver daughter tells the nurse, "You don't have to worry about me. My daughter cried and apologized. She promised me she will never hit me again." The nurse recognizes that the client is describing which stage of the cycle of violence? Acute battering Escalation Tension building Honeymoon
Honeymoon
Which issue should the nurse discuss when planning end-of-life care for a terminal ill client? (Select all that apply.) Cost of needed services Hospice admission Symptom management Curative therapies Advance directive planning
Hospice admission Symptom management Advance directive planning
A client has a history of demonstrating aggression physically. What short-term goal will best help the client manage this anger? Limit aggression to verbal outbursts. Isolate in lieu of striking people. Identify situations that precipitate hostility. Strike objects rather than people.
Identify situations that precipitate hostility.
When treating impulse control disorders, psychodynamic psychotherapy is directed toward which goal? Teaching the client self-distracting techniques Mastering relaxation techniques Helping the client replace the rage with acceptable alternative feelings Identifying the triggers of the rage
Identifying the triggers of the rage
Clients demonstrating characteristics of personality disorders have various self-defeating behaviors and interpersonal problems despite having near-normal ego functioning and intact reality testing. Which nursing diagnosis best addresses this sort of interpersonal dysfunction? A. Defensive coping B. Spiritual distress C. Impaired social interaction D. Disturbed sensory perception
Impaired social interaction
The clinical nurse specialist should suggest which cognitive intervention initially for a client experiencing auditory hallucinations? Seclusion when escalation begins Initiating a distracting technique Physical restraints when the client is disruptive Giving as-needed medication for anxiety
Initiating a distracting technique
Which statement would be an appropriate long-term outcome for a rape client? Appropriately blame the rapist rather than blaming herself for the situation. Integrate of the rape event and resumption of an optimal level of functioning Identify and develop coping skills necessary to reduce level of anxiety. Repress feelings of shame, embarrassment, and self-blame.
Integrate of the rape event and resumption of an optimal level of functioning
A client comes to the crisis intervention clinic and tearfully tells the nurse, "It is so painful! I have thought about it, and I cannot see how I can go on without my partner." The nurse states, "You have resilience and will look back on this as a crisis you were able to manage." Analysis of this interaction reveals what evaluation of the nurse's response? It demonstrates a good understanding of the effect of time on perception of a crisis. It is offering a statement of positive outcome based on client coping ability. It has failed to follow up on the client's verbal clues to suicidal thoughts. It has introduced a concept associated with traditional psychotherapy.
It has failed to follow up on the client's verbal clues to suicidal thoughts.
An adolescent is swearing and shouting at the primary care provider who refused to agree to a pass to leave the unit. What is the primary importance of this behavior? It may reduce tension and prevent the client from physically acting out. It can be attributed to lack of parental controls applied at an early age. It is acceptable if directed at staff but not when directed at other clients. It is a major indicator that the client may become physically aggressive.
It is a major indicator that the client may become physically aggressive.
What initial intervention should the nurse suggest to the family members of a client diagnosed with Alzheimer's disease who has become incontinence of urine? Provide toileting on an as-needed basis. Label the bathroom door with a picture. Apply disposable diapers. Encourage hourly toileting.
Label the bathroom door with a picture.
Which statement best reflects the way clients who are severely and persistently mentally ill generally perceive how others in the community see them? The majority are incapable of such self-reflective thought. Most feel under-supported by family and friends. A large number are intensely hostile toward others. Many feel stigmatized and alienated.
Many feel stigmatized and alienated.
A client reports insomnia and shares that a friend has recommended a nonprescription hormone product that can be purchased at the local health food store. The nurse suspects that the medication contains which component? A benzodiazepine A tranquilizer Melatonin Lithium
Melatonin
When providing care for a client diagnosed with borderline personality disorder, the nurse will need to consider strategies for dealing with which of the client's classic characteristics? A. Mood shifts, impulsivity, and splitting B. Altered sensory perceptions and suspicion C. Grief, anger, and social isolation D. Perfectionism and preoccupation with detail
Mood shifts, impulsivity, and splitting
A nurse attempts to intervene verbally when an angry client initially threatens to throw a chair but quickly focuses the anger toward the nurse. Several staff members gather behind the nurse, but then the client shouts, "I will calm down when that nurse isn't in my face." The nurse best demonstrates the ability to help the client deescalate by implementing which intervention? Continuing to manage the situation personally. Apologizing for upsetting the client. Moving outside of the client's personal space. Telling the client, "It isn't safe for me to leave the room."
Moving outside of the client's personal space.
Which situation has the potential for early crisis intervention to occur? Ms. G enters the emergency department with a strong smell of alcohol on his person, stating he is anxious and depressed. Ms. T is hospitalized after an unsuccessful suicide attempt that she states, "was a mistake." Mr. W asks for reassurance that he will be welcome at the day hospital after his hospital discharge. Mrs. R tells the nurse in the well-baby clinic that she's feeling uptight and has arranged to see a primary care therapist.
Mrs. R tells the nurse in the well-baby clinic that she's feeling uptight and has arranged to see a primary care therapist.
Which suicide prevention intervention that has the greatest impact on a client's safety? A. Restricting the client from potentially dangerous areas of the unit. B. Removal of personal items that might prove harmful. C. One-on-one observation by the staff. D. Educating visitors about potentially dangerous gifts.
One-on-one observation by the staff.
An elderly client is cognitively impaired and terminally ill with breast cancer. When asked if she is in pain, she usually denies it by shaking her head, but the nurses note that she lies rigidly in bed and grimaces when she turns from side to side. In an attempt to obtain a more accurate assessment, the nurses might choose to use which assessment tool? Present Pain Intensity Rating Scale. Pain Assessment in Advanced Dementia (PAINAD) scale. McGill Pain Questionnaire (MPQ). Wong-Baker FACES Scale.
Pain Assessment in Advanced Dementia (PAINAD) scale.
An older adult client is reporting symptomatology that suggests rapid eye movement (REM) sleep behavior disorder (RSBD). Which comorbid condition should the nurse assess for? Acute renal failure Lymphoma Parkinson's disease Hypertension
Parkinson's disease
A slightly obese client reports falling asleep during the daytime even though she has slept all night. Her husband says she snores, and her blood pressure is noted to be in the low hypertensive range. The nurse anticipates that the client will be scheduled for which diagnostic test? Hypertension screening Glycosylated hemoglobin Polysomnography Positron emission tomography
Polysomnography
When working with a client demonstrating impulse control disorders, which nursing interventions have initial priority? (Select all that apply.) Presenting appropriate expectations Establishing a therapeutic nurse-client relationship Confronting the client concerning the disruptive behavior Setting and enforcing limits Providing a safe environment
Presenting appropriate expectations Establishing a therapeutic nurse-client relationship Setting and enforcing limits Providing a safe environment
A client has been placed in seclusion to control aggressive behavior. Nursing care while the client is in mechanical restraints should include which intervention? Increasing sensory stimulation Providing regularly scheduled nutrition and hydration Releasing the client every 8 hours Observation every 30 minutes
Providing regularly scheduled nutrition and hydration
A client is treated in the emergency department for injuries sustained while vacationing hundreds of miles away from home. How should the nurse best meet the client's emotional needs in order to minimize the risk of crisis? Providing temporary support by arranging shelter for the client and contacting family or traveling companions. Suggesting that contacting a victim support group would be more appropriate than crisis intervention. Arranging to hospitalize the client so all needs will be met. Referring the client for traditional psychotherapy for the expected development of posttraumatic stress disorder.
Providing temporary support by arranging shelter for the client and contacting family or traveling companions.
The nurse working with a client diagnosed with severe and persistent mental illness will implement rehabilitation principles by concentrating on which intervention? Assessment on the client's deficits Considering the need to lower expectations periodically Reinforcing the client's strengths Reviewing earlier treatment plans for errors
Reinforcing the client's strengths
A sexual assault victim asks to be given "the morning-after pill" to prevent conception. The nurse does not believe in abortion. What action the nurse should take? Report and document the request. Ask the supervising nurse to reassign the client. Ask the client to reevaluate her request after 24 hours. Refer the woman for social services counseling.
Report and document the request.
A newly admitted client has a diagnosis of schizoid personality disorder. The nursing intervention of highest priority will be directed toward which classic client need? A. Set firm limits on behavior. B. Encourage expression of feelings. C. Respect need for social isolation. D. Involve in milieu and group activities
Respect need for social isolation.
Which statement accurately applies to exhibitionism? Generally viewed as an illness by the courts. Generally viewed as a victimless crime. Rarely prosecuted. Seldom a precursor to sexual assault or rape.
Seldom a precursor to sexual assault or rape.
A client confides to the nurse that she is sexually excited by dominating her partner and achieves orgasm only when she humiliates her partner. This admission supports which sexual disorder? Sexual sadism Orgasmic disorder Sexual pain disorder Immature sexual gratification
Sexual sadism
A client diagnosed with a severe and persistent mental illness tells the case manager, "I think people are laughing at me behind my back. I get real upset and anxious when I have to be around others in the group home. It's better when I just stay by myself." The nurse should consider which nursing diagnosis to address the client's concerns? Acute confusion Impaired comfort Risk for activity intolerance Social isolation
Social isolation
A client who lives with an adult child is quite self-sufficient but tells the community health nurse that "it gets lonely being by myself so much of the time with only the television set for company." What suggestion should the nurse make to address the client's need for socialization? Attend an adult day health program daily. Spend time at the local senior's center three times a week. Have the neighborhood watch visit once daily. Attend a maintenance day care program daily
Spend time at the local senior's center three times a week.
Which factor will have the greatest impact on end-of-life nursing care in the coming decades? Decrease in federal funding for healthcare The aging of the Baby Boomers generation The decline in those entering the nursing profession Technological advancements
The aging of the Baby Boomers generation
What is the priority concern of the crisis intervention nurse regarding the client? Helping the client brainstorm possible solutions Assisting the client to work through termination issues associated with therapy Setting up support contacts The client's physical safety
The client's physical safety
A terminally ill client expresses to the nurse the desire to discuss end-of-life issues. What is likely to be the greatest barrier to that discussion? The client's lack of knowledge regarding the various issues The health provider's hesitancy to prescribe palliative care The family's unwillingness to acknowledge the inevitable The nurse's reluctance to discuss death-related issues
The nurse's reluctance to discuss death-related issues
The risk of elder abuse in a home is best determined by conducting which assessment? The financial contribution of the elder and the caregiver's early life experience with abuse How much actual physical assistance the elder needs on a daily basis The vulnerability of the elder and the stress of the caregiver The amount of disruption the elder causes in the home
The vulnerability of the elder and the stress of the caregiver
Which statement is true about the characteristics of the oppositional defiant child? These behaviors are a predictor of future mental health disorders. Girls display more blaming than do boys. The defiance is generally directed toward parents and siblings. Arguing tends to be more prevalent in boys.
These behaviors are a predictor of future mental health disorders.
When parents share that their 8-year-old child seems to "always try to be annoying and hateful," the nurse suspects the child is demonstrating which characteristic? Anxiety Depression Emotionally immature Vindictiveness
Vindictiveness
What are the most important characteristics for staff members who work with suicidal clients? Organization Warm, consistent interaction Problem-solving skills Effective interview and counseling skills
Warm, consistent interaction
An angry client frequently loses patience with the nurses and shouts at them while they perform a complicated dressing change. Which plan could they create to intervene effectively in this behavior that focuses on behavior therapy concepts? When the client begins to become abusive, the nurse suggests returning in 20 minutes when he has regained control. Assuring him they will complete the dressing change as quickly as possible. Explaining that they are professionals and unused to being shouted at by people they are trying to help. Telling him they will not change his dressing if he is going to abuse them.
When the client begins to become abusive, the nurse suggests returning in 20 minutes when he has regained control.
Correctional nurses frequently work with inmates without what associated knowledge? nature of the inmate's alleged offense. sentence that an inmate must serve. inmate's medical history. length of time that an inmate has been incarcerated.
nature of the inmate's alleged offense.
Hormone therapy for the purpose of surgical gender reassignment is initiated when the client has demonstrated what behavior? taken on the dress and manners of the preferred gender. taken all legal steps to change name and legal status. successfully demonstrated a genuine intent to change genders. successfully lived the cross-gender role in all aspects of life.
successfully lived the cross-gender role in all aspects of life.