Mental Health

Which statement made by an assistive personnel (AP) indicates to the registered nurse that the AP understands the concepts related to suicide? 1. "Discussing suicide with a client is not harmful." 2. "Those clients who talk about suicide never do it." 3. "Depressed clients are the only persons who commit suicide." 4. "A suicide threat is a cry for attention from family and friends."

1. "Discussing suicide with a client is not harmful." **An open discussion of suicide will not encourage a client to make a decision to commit suicide and in fact often will help to prevent it. Such a discussion offers the health care professional the opportunity to assess the reality of suicide for the client and take necessary precautions to keep the client safe. The remaining options are inaccurate statements regarding suicide.

Which client is at greatest risk for committing suicide? 1. A client with metastatic cancer 2. A client with a newly diagnosed cardiac disorder 3. A client who just had an argument with the fiancé 4. A newly divorced client who states has custody of the children

1. A client with metastatic cancer **The person at greatest risk for suicide is the client with terminal illness. Other high-risk groups include adolescents, drug abusers, persons who have experienced recent losses, those who have few or no social supports, and those with a history of suicide attempts and a suicide plan.

A client calls the nurse and reports feeling anxious. What is the appropriate initial nursing action? 1. Sit and talk with the client about the feelings. 2. Ask the assistive personnel to check on the client. 3. Administer the prescribed as-needed antianxiety medication. 4. Call the client's primary health care provider to report the client's anxiety.

1. Sit and talk with the client about the feelings. **The appropriate initial nursing action is to sit and talk with the client expressing anxiety. An assistive personnel is not prepared to deal with the client's anxiety. Antianxiety medication may be necessary, but this would not be the initial appropriate nursing action. While it may become necessary, calling the health care provider is premature initially.

The nurse is creating a plan of care for a client diagnosed with depression whose food intake is poor. The nurse would include which interventions in the plan of care? Select all that apply. 1. Assist the client in selecting foods from the food menu. 2. Offer high-calorie fluids throughout the day and evening. 3. Allow the client to eat alone in the room if the client requests to do so. 4. Offer small high-calorie, high-protein snacks during the day and evening. 5. Select the foods for the client to be sure that the client eats a balanced diet.

1. Assist the client in selecting foods from the food menu. 2. Offer high-calorie fluids throughout the day and evening. 4. Offer small high-calorie, high-protein snacks during the day and evening. **In caring for a client with depression whose nutritional intake is poor, the nurse needs to remain with the client during the meal. The nurse also would assist the client in selecting foods from the menu because the client is more likely to eat the foods that they like. Offering small high-calorie, high-protein snacks and high-calorie fluids throughout the day and evening are appropriate interventions for the client to maintain nutrition.

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent gives away a DVD and a cherished autographed picture of a performer. 2. The adolescent runs out of the therapy group, swearing at the group leader, and to own room. 3. The adolescent becomes angry while speaking on the telephone and slams down the receiver. 4. The adolescent gets angry with the roommate when the roommate borrows the client's clothes without asking.

1. The adolescent gives away a DVD and a cherished autographed picture of a performer. **A depressed suicidal client often gives away that which is of value as a way of saying goodbye and wanting to be remembered. **Options 2, 3, and 4 deal with anger and acting-out behaviors that are often typical of an adolescent.

The nurse is performing an admission assessment on a client at high risk for suicide. Which assessment question will best elicit data related to this risk? 1. "What are you feeling right now?" 2. "Do you have a plan to commit suicide?" 3. "How many times have you attempted suicide in the past?" 4. "Why were your attempts at suicide unsuccessful in the past?"

2. "Do you have a plan to commit suicide?" **When assessing for suicide risk, the nurse must determine whether the client has a suicide plan. Clients who have a definitive plan pose a greater risk for suicide. **Although the other options are questions that may provide information that will be helpful in planning care for the client, these questions will not provide information regarding the risk of suicide.

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention would the nurse include? 1. Increase socialization of the client with peers. 2. Avoid using a whisper voice in front of the client. 3. Begin to educate the client about social supports in the community. 4. Have the client sign a release of information to appropriate parties for assessment purposes.

2. Avoid using a whisper voice in front of the client. **Disturbed thought processes related to paranoid personality disorder are the client's problem, and the plan of care must address this problem. The client is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client with this disorder.

When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2. Identifying anxiety-producing situations 3. Continuing contact with a crisis counselor 4. Eliminating all anxiety from daily situations

2. Identifying anxiety-producing situations **Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. **Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.

A newly admitted client is exhibiting signs and symptoms associated with a loss of physical functioning, although no such loss can be confirmed medically. This situation supports which mental health diagnosis? 1. Depression 2. Somatization disorder 3. Post-traumatic stress disorder 4. Obsessive-compulsive disorder

2. Somatization disorder **Emotional turmoil expressed in physical signs is the hallmark of somatization disorder. None of the other options are associated with loss of physical function.

The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect? 1. When told that a beloved pet has died, the client responds, "OK." 2. The client giggled while describing being physically abused as a child. 3. The client's facial expressions are unchanged during the entire admission process. 4. When staff members attempt to engage the client in conversation, the client only mumbles.

2. The client giggled while describing being physically abused as a child. **An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A flat affect is manifested as an immobile facial expression or blank look. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions.

The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? 1. "I see." 2. "Really?" 3. "You're having difficulty sleeping?" 4. "Sometimes I have trouble sleeping too."

3. "You're having difficulty sleeping?" **The correct option uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client's major theme, which assists the nurse to obtain a more specific perception of the problem from the client. **The remaining options are non therapeutic responses since none encourages the client to expand on the problem. Offering personal experiences moves the focus away from the client and onto the nurse.

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How would the nurse interpret this behavior as a cue to modify the treatment plan? 1. Suggesting a reduction of medication 2. Allowing increased "in-room" activities 3. Increasing the level of suicide precautions 4. Allowing the client off-unit privileges as needed

3. Increasing the level of suicide precautions **A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm self. Suicide precautions are necessary to keep the client safe.

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client? 1. Display an attitude of detachment, confrontation, and efficiency. 2. Demonstrate confidence in the client's ability to deal with stressors. 3. Provide authority, action, and assistance with problem-solving. 4. Provide hope and reassurance that the problems will resolve themselves.

3. Provide authority, action, and assistance with problem-solving. **A crisis is an acute, time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A person in this state is temporarily unable to cope with or adapt to the stressor by using previous coping mechanisms. The person who intervenes in this situation (the nurse) "takes over" (authority) for the client who is not in control and devises a plan (action) to secure and maintain the client's safety. When this has occurred, the nurse works collaboratively with the client (assistance) in developing new coping and problem-solving strategies.

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1. Begin to teach relaxation techniques. 2. Encourage the client to discuss the assault. 3. Remain with the client until the anxiety decreases. 4. Place the client in a quiet room alone to decrease stimulation.

3. Remain with the client until the anxiety decreases. **This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. **The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client's level of anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.

The nurse in the mental health unit is performing an assessment on a client who has a history of multiple physical complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder? 1. Depression 2. Schizophrenia 3. Somatization disorder 4. Obsessive-compulsive disorder

3. Somatization disorder **Somatization disorder is characterized by a long history of multiple physical problems with no satisfactory organic explanation. The clinical findings associated with schizophrenia, depression, and obsessive-compulsive disorder are unrelated to somatic complaints.

A nurse attends an educational session on family violence. Which statement by the nurse indicates a need for further teaching concerning family violence? 1. "Abusers use fear and intimidation." 2. "Abusers usually have poor self-esteem." 3. "Abusers often are jealous or self-centered." 4. "Abusers are more often from low-income families."

4. "Abusers are more often from low-income families." **Personal characteristics of abusers include low self-esteem, immaturity, dependence, insecurity, and jealousy. Abusers often use fear and intimidation to the point at which their victims will do anything just to avoid further abuse. **The statement that abuse occurs more often in lower socioeconomic groups is incorrect.

During a therapy session a client with a personality disorder says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would best address this breach of boundaries? 1. "Thank you, the perfume was a gift." 2. "Your comment is really inappropriate." 3. "Neither my hair nor my perfume is the focus of today's session." 4. "The focus of today's session is on your issues, so let's get started."

4. "The focus of today's session is on your issues, so let's get started." **The therapeutic response by the nurse is the one that clarifies the content of the client's statements and directs the client to the purpose of the session. The nurse would confront the client verbally regarding the inappropriate statements and refocus the client back to the issue of the session. Avoid options that may be judgmental and may provide an opening for a verbal struggle or those that are a social response and could be misinterpreted by the client.

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1. "This form of therapy can be applied to new situations." 2. "An advantage of this technique is that change is likely to last." 3. "Talking to oneself is a basic component of this form of therapy." 4. "This form of therapy provides a negative reinforcement when the stimulus is produced."

4. "This form of therapy provides a negative reinforcement when the stimulus is produced." **Negative reinforcement when the stimulus is produced is descriptive of aversion therapy.

The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action would the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function 2. Exploring the client's potential for self-harm 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4. Inquiring about and examining the client's feelings for any that may block adaptive coping

4. Inquiring about and examining the client's feelings for any that may block adaptive coping **The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. The correct option pertains directly to the client's feelings and is client-focused. The remaining options do not directly focus on or address the client's feelings.

The nurse is preparing a client with schizophrenia for discharge. The client has a history of command hallucinations, and the nurse is providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? 1. "My medications will help my anxious feelings." 2. "I'll go to support group and talk about what I am feeling." 3. "I need to get enough sleep and eat well to help prevent feeling anxious." 4. "When I have command hallucinations, I'll call a friend and ask what I should do."

4. "When I have command hallucinations, I'll call a friend and ask what I should do." **The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations especially if the hallucination is commanding to harm self or others. If the client is experiencing a hallucination, the nurse or health care counselor, not a friend, should be contacted to discuss whether the client has intentions to hurt self or others. The client statements in the remaining options will aid in wellness and are helpful.

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? 1. Incessant talking and sexual innuendos 2. Grandiose delusions and poor concentration 3. Outlandish behaviors and inappropriate dress 4. Nonstop physical activity and poor nutritional intake

4. Nonstop physical activity and poor nutritional intake **Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible symptoms. However, the correct option clearly presents a problem that compromises physiological integrity and needs to be addressed immediately.

A client diagnosed with depression is not eating adequately and at times refuses to eat at all. What would the nurse plan to do to meet the client's nutritional needs? 1. Force foods and fluids. 2. Restrict social activities until food intake is increased. 3. Promptly provide snacks and meals when the client requests them. 4. Provide small, frequent meals that include the client's food preferences.

4. Provide small, frequent meals that include the client's food preferences. **A depressed client may eat small amounts of food because large amounts may seem overwhelming. If the client becomes overwhelmed, he or she may respond by withdrawing further. Forcing foods and fluids and restricting social activities will cause further withdrawal by the client since both will be viewed as a punishment. Providing snacks and meals when the client requests them will not ensure adequate nutritional intake.

What is the appropriate nursing intervention for a client diagnosed with post-traumatic stress disorder and paranoid tendencies who begins to pace and fidget? 1. Escort the client to a private, low-stimulus room. 2. Engage the client in a nonthreatening conversation. 3. Allow the client to pace unless the behavior becomes aggressive. 4. Share the observation with the client so that the behavior can be recognized.

4. Share the observation with the client so that the behavior can be recognized. **Sharing observations with the client may help the client recognize and acknowledge feelings. Allowing the client to pace may also allow the client to get out of control. Moving to a quiet room or changing the subject will not help the client to recognize their behaviors and feelings.

A client with an anxiety disorder is experiencing disturbed thought processes and believes that the food is being poisoned. Which communication technique would the nurse use to encourage the client to eat? 1. Using open-ended questions and silence 2. Sharing personal preferences regarding food choices 3. Documenting reasons why the client does not want to eat 4. Offering opinions about the necessity of adequate nutrition

1. Using open-ended questions and silence **Open-ended questions and silence are strategies used to encourage clients to discuss their problems. **Sharing personal food preferences is not a client-centered intervention. The remaining options are unhelpful to the client because they do not encourage the client to express feelings. The nurse would not offer opinions and would encourage the client to identify the reasons for the behavior.

During a nursing interview, a client says, "My child was murdered. I can't help wondering if the spouse killed my child, but they have been eliminated as a suspect." Which statement is a therapeutic nursing response? 1. "I agree. What do you want to bet the spouse did it?" 2. "Have you shared your concerns with the police?" 3. "I don't think that you should blame yourself one little bit." 4. "It feels terrible to lose a child. Your suspicions are only natural."

2. "Have you shared your concerns with the police?" **The correct option addresses the subject of the client's statement. Avoid options that identify the process of agreeing with the client. The option of telling the client "I don't think that you should blame yourself" is not directly related to the subject of the client's statement.

A nursing student is assisting with the care of a client with a chronic mental illness. The nurse informs the student that a behavioral modification approach (operant conditioning) will be used in treatment for the client. Which statement by the student indicates a need for further information about the therapy? 1. "It uses positive reinforcement." 2. "It uses negative reinforcement." 3. "It increases social behaviors in the client." 4. "It increases the level of self-care in the client."

2. "It uses negative reinforcement." **Operant conditioning entails rewarding a client for desired behaviors and is the basis for behavior modification. It uses a positive reinforcement approach. Positive reinforcement, increases in social behaviors, and increases in the level of self-care are accurate characteristics of this form of therapy.

The nurse assigned to care for a client diagnosed with acute depression would be appropriate in making which statement to the client? 1. "You look lovely today." 2. "You're wearing a new blouse." 3. "Don't worry; everyone gets depressed once in a while." 4. "You will feel better when your medication starts to work."

2. "You're wearing a new blouse." **A client who is depressed sees the negative side of everything. Telling the client that they look lovely today can be interpreted as "I didn't look lovely last time we met." Neutral comments such as that identified in the correct option will avoid negative interpretations. The client would not be told not to worry, that everyone gets depressed once in a while, or that they will feel better because such statements are inappropriate and minimize the client's feelings.

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicate effective coping? Select all that apply. 1. Neglecting personal grooming 2. Looking at old photographs of family 3. Participating in a senior citizens program 4. Visiting the spouse's grave once a month 5. Decorating a wall with the spouse's pictures and awards received

2. Looking at old photographs of family 3. Participating in a senior citizens program 4. Visiting the spouse's grave once a month 5. Decorating a wall with the spouse's pictures and awards received **Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. Neglecting personal grooming is indicative of a behavior that identifies ineffective coping in the grieving process. The remaining options identify appropriate and effective coping mechanisms.

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1. Chess 2. Writing 3. Ping pong 4. Basketball

2. Writing **Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them and should be avoided because they can stimulate aggression and increase psychomotor activity.

A client who has recently lost their spouse says, "No one cares about me anymore. All the people I loved are dead." The nurse would make which therapeutic response when dealing with a grieving client? 1. "I certainly care about you." 2. "I don't believe that and neither should you." 3. "You must be feeling all alone at this point." 4. "It isn't unusual to feel alone when you are grieving."

3. "You must be feeling all alone at this point." **The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is the one that attempts to translate words into feelings. None of the remaining options encourage the client to discuss feelings but rather minimize and/or trivialize the feelings expressed.

The nurse is caring for a client just admitted to the mental health unit; the client is displaying immobile and mute behaviors and is withdrawn. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention? 1. Ask direct questions to encourage talking. 2. Leave the client alone so as to minimize external stimuli. 3. Sit beside the client in silence with occasional open-ended questions. 4. Take the client into the dayroom with other clients so that they can help watch the client.

3. Sit beside the client in silence with occasional open-ended questions. **Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. While overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client's safety is not the responsibility of other clients.

Which assessment data would indicate that a client is most at risk for suicide? 1. The client demonstrates impulsiveness. 2. The client is disorganized in actions and thoughts. 3. The client has an immediate plan for a suicide attempt. 4. The client has a history of unsuccessful suicide attempts.

3. The client has an immediate plan for a suicide attempt. **Having a plan, particularly if the method is immediate and available, places the client at very high risk. Clients also at higher risk include those with a history of a dual diagnosis of mental illness and substance abuse; those with a personal or family history of suicide attempts, depression, or alcoholism; or those with a history of psychotic episodes. Although impulsiveness, disorganization in actions and thoughts, and previous suicide attempts are related to suicide risk, these are not data that make the client most at risk from the options provided.

Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client with depression? 1. Restrict the client from smoking for 12 hours. 2. Enforce nothing by mouth (NPO) status for 16 hours. 3. Limit the client's participation in unit activities for 24 hours. 4. Assure that an electrocardiogram is performed within 24 hours.

4. Assure that an electrocardiogram is performed within 24 hours. **Before electroconvulsive therapy (ECT), blood tests are performed and an electrocardiogram is done to determine a baseline status of the client. Maintaining NPO status for 6 to 8 hours before treatment is adequate. The remaining options are incorrect.

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1. Ask the client to leave the group for this session only. 2. Refer the client to another group that includes other manic clients. 3. Tell the client to stop monopolizing in a firm but compassionate manner. 4. Thank the client for the input, but inform the client that others now need a chance to contribute.

4. Thank the client for the input, but inform the client that others now need a chance to contribute. **If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although telling the client to stop monopolizing in a firm but compassionate manner may be a direct response, the correct option is more specific and provides direction for the client. The remaining options are inappropriate since they are not directed toward helping the client in a therapeutic manner.

The nurse determines that the spouse of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the spouse make which statement? 1. "I no longer feel that I deserve the beatings my spouse inflicts on me." 2. "My attendance at the meetings has helped me to see that I provoke my spouse's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my spouse." 4. "I can tolerate my spouse's destructive behaviors now that I know they are common among alcoholics."

1. "I no longer feel that I deserve the beatings my spouse inflicts on me." **Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for their own behavior and cannot be allowed to blame family members for loss of control. **Option 2 is incorrect because the nonalcoholic partner should not feel responsible when the spouse loses control. Option 3 indicates that the group is viewed as an escape, not as a place to work on issues. Option 4 indicates codependence.

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my doctor's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation? 1. An expected coping mechanism 2. An ineffective defense mechanism 3. A need to notify the hospital lawyer 4. An expression of guilt on the part of the client

1. An expected coping mechanism **The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, God or other spiritual being, or caregivers. **Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the client's feelings, and the data in the question do not indicate that guilt is present.

On review of the client's record, the nurse notes that the admission to the mental health unit was voluntary. Based on this information, the nurse plans care, anticipating which client behavior? 1. Fearfulness regarding treatment measures 2. Anger and aggressiveness directed toward others 3. An understanding of the pathology and symptoms of the diagnosis 4. A willingness to participate in the planning of the care and treatment plan

4. A willingness to participate in the planning of the care and treatment plan **In general, clients seek voluntary admission. If a client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program since they are actively seeking help. **The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee that a client understands the illness, only the client's desire for help.

The mental health nurse notes that a client diagnosed with schizophrenia is exhibiting flat affect. Which situation supports this documentation? 1. During the entire family visit, the client presented with an expressionless, blank look. 2. The client demonstrated minimal response to the news that his discharge had been postponed. 3. The client grimaced during the entire therapy session that focused on finding one's personal joy. 4. During grief therapy, the client was observed laughing while another client described the death of a parent.

1. During the entire family visit, the client presented with an expressionless, blank look. **A flat affect is manifested as an immobile facial expression or blank look. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation.

A homebound client confidentially discusses suicidal plans with the visiting nurse. Based on professional duty to observe confidentiality, which statement describes the nurse's obligation to the client? 1. Arrange for the client to go to the local mental health center daily for counseling. 2. Ask the client's permission to reveal the suicidal plans to the primary health care provider (PHCP). 3. Assure the client that the confidence between nurse and client will be strictly adhered to. 4. Share that the risk to the client's safety requires that the client's PHCP be notified.

4. Share that the risk to the client's safety requires that the client's PHCP be notified. **In this situation, the nurse must override the duty to observe confidentiality and must notify the client's PHCP about the client's suicidal ideation. The nurse's first duty is to keep the client safe. None of the other options addresses the client's need for protection regarding his or their suicidal ideations.

The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concern regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? 1. Anxiety 2. Unrealistic outlook 3. Lack of ability to cope effectively 4. Disturbances in thoughts and ideas

3. Lack of ability to cope effectively **Lack of ability to cope effectively may be evidenced by a client's inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. **Anxiety is a broad description and can occur as a result of many triggers; although the client was experiencing anxiety, the client's concern now is the ability to meet role expectations and financial obligations. There is no information in the question that indicates an unrealistic outlook or disturbances in thoughts and ideas.

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse would tell the client that which is the first step in this 12-step program? 1. Admitting to having a problem 2. Substituting other activities for gambling 3. Stating that the gambling will be stopped 4. Discontinuing relationships with people who gamble

1. Admitting to having a problem **The first step in the 12-step program is to admit that a problem exists. **Substituting other activities for gambling may be a strategy, but it is not the first step. The remaining options are not realistic strategies for the initial step in a 12-step program.

The nurse creating a plan of care for the client demonstrating paranoia would include which interventions in the plan of care? Select all that apply. 1. Ask permission before touching the client. 2. Provide a warm, social approach to the client. 3. Eliminate all unnecessary physical contact with the client. 4. Defuse any anger or verbal attacks with a nondefensive stance. 5. Use simple and clear language when communicating with the client.

1. Ask permission before touching the client. 3. Eliminate all unnecessary physical contact with the client. 4. Defuse any anger or verbal attacks with a nondefensive stance. 5. Use simple and clear language when communicating with the client. **When caring for a client with paranoia, the nurse would ask permission if touch is necessary because touch may be interpreted as a sexual or physical assault. The nurse must eliminate any physical contact and not touch the client unless necessary and with the client's permission. The anger that a paranoid client expresses often is displaced, and when a staff member becomes defensive, both client and staff anger may escalate. Simple and clear language would be used in speaking to the client to prevent misinterpretation and to clarify the nurse's intent and action. The nurse would avoid a warm approach because warmth can be frightening to a person who needs emotional distance.

The nurse is preparing a client with depression for electroconvulsive therapy, which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply. 1. Have the client void. 2. Obtain an informed consent. 3. Administer tap water enemas. 4. Avoid discussing the procedure. 5. Remove dentures and contact lenses. 6. Withhold food and fluids for 6 hours.

1. Have the client void. 2. Obtain an informed consent. 5. Remove dentures and contact lenses. 6. Withhold food and fluids for 6 hours. **Enemas are not a component of the pretreatment care for a client scheduled for electroconvulsive therapy (ECT). The nurse would teach the client and family what to expect with ECT and allow the client to discuss their feelings regarding the procedure. The remaining options are a part of the pretreatment plan.

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. 1. Restating 2. Listening 3. Asking the client "Why?" 4. Maintaining neutral responses 5. Providing acknowledgment and feedback 6. Giving advice and approval or disapproval

1. Restating 2. Listening 4. Maintaining neutral responses 5. Providing acknowledgment and feedback **Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. **Asking why is often interpreted as being accusatory by the client and should also be avoided. Providing advice or giving approval or disapproval are barriers to communication.

Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia? 1. The client's noncompliance with medication therapy 2. The community's opposition to outpatient mental health clinics 3. The associated increased risk that the client may become homeless 4. The family's negative reaction to transferring the client to community-based care

1. The client's noncompliance with medication therapy **Clients often forget to take their medications as scheduled, and this is the most prominent problem since medication therapy is vital to the function of clients with such a diagnosis. While the situations described in the remaining options may occur, these problems are not as impacting on the client's prognosis and can be addressed and often controlled.

The mental health nurse is meeting with a client who has a long history of abusing drugs. During the session the client says to the nurse, "I'm feeling much better now, and I'm ready to stop using drugs." Which response by the nurse would be therapeutic? 1. "You have said this many times before!" 2. "Tell me what makes you feel that you are ready." 3. "I'm so glad to hear you talking this way. I will let your psychiatrist know." 4. "I need to see changes in you to believe that you are ready to stop using drugs."

2. "Tell me what makes you feel that you are ready." **Clients with a long history of drug abuse need to demonstrate motivation to change the behavior, not just verbalization of the intent to change the behavior. The therapeutic response by the nurse would be directed at assisting the client to look at the behaviors that indicate the change. The correct option is the only one that will provide this direction to the client.

The nurse tells the client that a music therapy session has been scheduled as part of the treatment plan. The client tells the nurse, "I can't sing," and refuses to attend. Which nursing response is most likely to meet the client's needs? 1. "Why don't you want to attend? What is the real reason?" 2. "You don't have to sing. Just listen and enjoy the music." 3. "You must go. You have no choice if you want to get better." 4. "Your primary health care provider has prescribed this therapy for you."

2. "You don't have to sing. Just listen and enjoy the music." **The correct option encourages the client to socialize and indicates that it is not necessary to sing. Avoid the use of the word why since it can be insulting to the client. Don't make or imply a demand. Focus on addressing the client's concern. The correct option is the only one that addresses the client's concern.

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply. 1. Initiate confinement measures. 2. Acknowledge the client's behavior. 3. Assist the client to an area that is quiet. 4. Maintain a safe distance from the client. 5. Allow the client to take control of the situation.

2. Acknowledge the client's behavior. 3. Assist the client to an area that is quiet. 4. Maintain a safe distance from the client. **During the escalation period, the client's behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. **To initiate confinement measures during this period is inappropriate. Initiation of confinement measures, if needed, is most appropriate during the crisis period.

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action would the nurse take to plan appropriate nursing care? 1. Ask the client about the reason for taking illegal drugs. 2. Ask the client about the amount of drug use and its effect. 3. Ask the client how long they thought they could take drugs without someone finding out. 4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

2. Ask the client about the amount of drug use and its effect. **Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. **Option 1 is incorrect because it is judgmental and off-focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is non therapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.

A 15-year-old pregnant, unwed client tells the nurse, "My life was unbearable before I met my partner. One of my parents beats me every day, and my other parent has sexually abused me since I was 10 years old!" Which response is appropriate for the nurse to make? 1. "Why didn't you just report your parents for this abuse?" 2. "What are you saying? Your parents abused you, so you got pregnant?" 3. "It seems that you needed your partner's help to separate from your family." 4. "Sounds as if you decided to have a baby so you'd have someone for yourself."

3. "It seems that you needed your partner's help to separate from your family." **Adolescent pregnancy outside marriage can arise from low self-esteem, fears of inadequacy, and desperation to escape from an abusive and dysfunctional family. The most therapeutic communication technique is the one that uses restatement and repeats the main thought that the client expressed. This assures the client that the nurse is listening and is attempting to validate what the client has said. The remaining options are nontherapeutic because they reflect a knowledge deficit on the nurse's part, imply bias, are insensitive, or place responsibility on the adolescent.

A client diagnosed with depression shares with the outpatient clinic nurse, "I lost my job this week and can't pay my rent. My one child is my only family, but I don't want to burden my child with my problems." Which response by the nurse would best address the client's concern? 1. "Let's talk about the circumstances that caused you to lose your job." 2. "There are homeless shelters available for people who are experiencing this exact situation." 3. "Wouldn't you want to know if your child was having difficulties so that you could help if you could?" 4. "Being homeless would allow us to admit you to the hospital so that you will have a place to eat and sleep."

3. "Wouldn't you want to know if your child was having difficulties so that you could help if you could?" **The therapeutic communication technique of clarification in option 3 attempts to put vague ideas into words. It helps the client to view the explicit correlation between the client's feelings and actions. **Asking why a client lost a job is not directly related to the client's feelings and concerns. Offering to provide a homeless shelter or to commit the client to the hospital does not address the issue at hand and places the client's concerns and feelings on hold.

A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action? 1. Requesting that a peer remain with the client at all times 2. Removing the client's clothing and placing the client in a hospital gown 3. Assigning to the client a staff member who will remain with the client at all times 4. Admitting the client to a seclusion room where all potentially dangerous articles are removed

3. Assigning to the client a staff member who will remain with the client at all times **Hanging is a serious suicide attempt. The plan of care must reflect action that ensures the client's safety. Constant observation status (one-to-one) with a staff member is the best choice. **Placing the client in a hospital gown and requesting that a peer remain with the client would not ensure a safe environment. Seclusion would not be the initial intervention, and the least restrictive measure needs to be used.

A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention would the nurse implement? 1. Place the client in seclusion for 30 minutes. 2. Tell the client that the behavior is inappropriate. 3. Escort the client to the hospital room, with the assistance of other staff. 4. Tell the client that telephone privileges are revoked for 24 hours.

3. Escort the client to the hospital room, with the assistance of other staff. **The client is at risk for injury to self and others and would be escorted out of the dayroom. **Seclusion is premature in this situation. Telling the client that the behavior is inappropriate has already been attempted by the nurse. Denying privileges may increase the agitation that already exists in this client.

Parents tell the nurse in a pediatrician's office that they are concerned because their children must let themselves into the house after school each day while they are at work. The nurse explores which suggestion with the parents to decrease the children's sense of isolation and fear? 1. Instruct the children never to cook. 2. Let the children play in neighborhood homes. 3. Find community after-school programs or activities. 4. Have the children call a parent at work every hour.

3. Find community after-school programs or activities. **In most communities, free or low-cost after-school programs or activities are available that minimize the amount of time during which school-age children are at home alone. These programs would include adult supervision, which is needed by school-age children. **Prohibiting cooking enhances safety but does not address isolation and fear. Neighborhood play is inadequate because no one is assuming responsibility for the after-school safety of the children; no formal agreement to provide child care has been made with the other families. Calling a parent at work hourly may reassure the parent that the children are home and safe, but it does not address feelings of isolation and fear.

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How would the nurse plan to respond to the client's statement? 1. Reassure the client that things will get better. 2. Tell the client that this is not true and that we all have a purpose in life. 3. Identify recent behaviors or accomplishments that demonstrate the client's skills. 4. Remain with the client and sit in silence; this will encourage the client to verbalize feelings.

3. Identify recent behaviors or accomplishments that demonstrate the client's skills. **Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging but that will not be met with failure. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. **Options 1 and 2 give advice and devalue the client's feelings. Silence may be interpreted as agreement.

The nurse is developing a plan of care for a client who experiences anxiety after the loss of a job. The client is verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? 1. Panic 2. Unrealistic outlook 3. Lack of ability to cope effectively 4. Disturbances in thoughts and ideas

3. Lack of ability to cope effectively **Lack of ability to cope effectively may be evidenced by a client's inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers; the client experiences anxiety, and the client's concern is the ability to meet role expectations and financial obligations. **There is no information in the question that indicates panic (fright or acute, extreme anxiety), an unrealistic outlook, or disturbances in thoughts and ideas.

Which activity would the nurse include in the plan of care for a client with mania who is experiencing psychomotor agitation? 1. Playing checkers with members of the staff 2. Reading in a quiet, low-stimulus environment 3. Engaging in a card game with other clients on the unit 4. Attending a clay-molding class that is scheduled for today

4. Attending a clay-molding class that is scheduled for today **When a client is experiencing psychomotor agitation, it is best to provide activities that involve the use of hands and gross motor movements. Such activities can include volleyball, finger painting, drawing, and working with clay. These activities provide an appropriate way for the client to discharge motor tension. Reading and simple card games are sedentary activities. Playing checkers requires concentration and more intensive use of thought processes.

A client recently admitted to the hospital in the manic phase of bipolar disorder is unkempt, taking antipsychotic medications, and complaining of abdominal fullness and discomfort. Which intervention addresses the priority sign/symptom? 1. Teach self-grooming skills. 2. Reward cleanliness with unit privileges. 3. Monitor the adequacy of the antipsychotic dosage. 4. Encourage frequent fluid intake and a high-fiber diet.

4. Encourage frequent fluid intake and a high-fiber diet. **Constipation is a common elimination problem with clients in a manic phase of bipolar disorder. Constipation may occur as the result of a combination of factors, including taking antipsychotic medications, suppressing the urge to defecate, and a decreased fluid intake as a result of the manic activity level. The symptoms listed in the question in combination with antipsychotic medications are indicators of constipation. A high-fiber diet and increased fluids can reduce constipation.

A depressed client who appeared sullen, distraught, and hopeless a few days ago now suddenly appears calm, relaxed, and more energetic. Which is the nurse's best initial action with regard to the client's altered demeanor? 1. Continue to assess the client's behaviors and document clearly in the chart. 2. Report to the psychiatrist that the client is adapting to the unit and is feeling safe. 3. Notify the health team of these observations and alert them to the suspicion that the client is contemplating suicide. 4. Engage the client in one-to-one supervision, share with the client the observations that have been assessed, and ask whether the client is thinking about suicide.

4. Engage the client in one-to-one supervision, share with the client the observations that have been assessed, and ask whether the client is thinking about suicide. **The sudden change in the depressed client's mood and affect may indicate that the client has come to a decision about suicide. The only way to be sure is to ask the client directly. Eliminate options that present strategies that would be used with any client. Avoid options that make unfounded assumptions such as a meaning of the behavior. Notifying others of your concern may be necessary at some point but does nothing to address the problem directly.

A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? 1. Platelet count 2. Cholesterol level 3. Blood urea nitrogen 4. White blood cell count

4. White blood cell count **Clozapine is an antipsychotic medication. Clients taking clozapine can experience hematological adverse effects, including agranulocytosis and mild leukopenia. The white blood cell count needs to be assessed before initiation of treatment and would be monitored closely during the use of this medication. The client also would be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. The remaining options are unrelated to this medication.