Mental health

5. A client diagnosed with obsessive-compulsive disorder states, "I really think my future will improve because of my successful treatment choices. I'm going to make my life better." Which guiding principle of recovery has assisted this client? 1. Recovery emerges from hope. 2. Recovery is person-driven. 3. Recovery occurs via many pathways. 4. Recovery is holistic.

1 Page: 216 Feedback 1 SAMHSA lists the following as guiding principles for the recovery model: Recovery emerges from hope. 2 SAMHSA lists the following as guiding principles for the recovery model: Recovery is person-driven. 3 SAMHSA lists the following as guiding principles for the recovery model: Recovery occurs via many pathways. 4 SAMHSA lists the following as guiding principles for the recovery model: Recovery is holistic.

11. A client states, "My illness is so devastating, I feel like my life is on hold." The nurse recognizes that this client is in which stage of the Psychological Recovery Model as described by Andersen and associates? 1. Moratorium 2. Awareness 3. Preparation 4. Rebuilding

1 Page: 222 Feedback 1 Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 1: Moratorium. 2 Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 2: Awareness. 3 Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 3: Preparation. 4 Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 4: Rebuilding.

13. A psychiatrist who embraces the Psychological Recovery Model tells the nurse that a client is in the Growth stage. What should the nurse expect to find when assessing this client? 1. A client feeling confident about achieving goals in life. 2. A client who is aware of the need to set goals in life. 3. A client who has mobilized personal and external resources. 4. A client who begins to actively take control of his or her life.

1 Page: 224 Feedback 1 Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. In the growth stage, the individual feels a sense of optimism and hope of a rewarding future. Skills that have been nurtured in the previous stages are applied with confidence, and the individual strives for higher levels of well-being. 2 Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 2: Awareness. 3 Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 3: Preparation. 4 Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 4: Rebuilding.

12. A nurse is caring for a client who has threatened to commit suicide by hanging. The client states, "I'm going to use a knotted shower curtain when no one is around." Which information would determine the nurse's plan of care for this client? 1. The more specific the plan is, the more likely the client will attempt suicide. 2. Clients who talk about suicide never actually commit it. 3. Clients who threaten suicide should be observed every 15 minutes. 4. After a brief assessment, the nurse should avoid the topic of suicide.

1 Page: 236 Feedback 1 Clients who have specific plans are at greater risk for suicide. 2 Clients who talk about suicide should be taken seriously. 3 One-to-one supervision should be provided for any client who threatens suicide. 4 The nurse should be direct and upfront when discussing suicide with clients and their families.

23. A client has been brought to the emergency department for signs and symptoms of chronic obstructive pulmonary disease (COPD). The client has a history of a suicide attempt 1 year ago. Which nursing intervention would take priority in this situation? 1. Assessing the client's pulse oximetry and vital signs 2. Developing a plan for safety for the client 3. Assessing the client for suicidal ideations 4. Establishing a trusting nurse-client relationship

1 Page: 237 Feedback 1 It is important to prioritize client interventions that assess the symptoms of COPD prior to any other nursing intervention. Physical needs must be prioritized according to Maslow's hierarchy of needs. This client's problems with oxygenation will take priority over assessing for current suicidal ideations as they can lead to death more quickly if not reversed. 2 Developing a plan for safety can occur after physical needs have been met. 3 Assessing for suicidal ideation can occur after physical needs have been met. 4 Establishing a nurse-client relationship can occur after physical needs have been met.

19. Which nursing intervention strategy is most important to implement initially with a suicidal client? 1. Ask a direct question such as, "Do you ever think about killing yourself?" 2. Ask client, "Please rate your mood on a scale from 1 to 10." 3. Establish a trusting nurse-client relationship. 4. Apply the nursing process to the planning of client care.

1 Page: 237 Feedback 1 The risk of suicide is greatly increased if the client has suicidal ideations, if the client has developed a plan, and particularly if the means exist for the client to execute the plan. 2 Asking the client to rate mood does not help assess suicide risk. 3 Establishing a nurse-client relationship does not help assess suicide risk. 4 Applying the nursing process to planning does not help assess suicide risk.

6. A client diagnosed recently with AD is prescribed donepezil (Aricept). The client's spouse inquires, "How does this work? Will this cure him?" Which is the appropriate nursing response? 1. "This medication delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease." 2. "This medication encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease." 3. "This medication delays the destruction of dopamine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease." 4. "This medication encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease."

1 Page: 269-270 Feedback 1 The most appropriate response by the nurse is to explain that donepezil delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD. Some side effects include dizziness, headache, gastrointestinal upset, and elevated transaminase. 2 The statement is inaccurate for donepezil (Aricept). 3 This statement provides the client with inaccurate information about donepezil (Aricept). 4 This statement regarding donepezil (Aricept) is false.

1. What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? 1. Risk for injury R/T central nervous system stimulation 2. Disturbed thought processes R/T tactile hallucinations 3. Ineffective coping R/T powerlessness over alcohol use 4. Ineffective denial R/T continued alcohol use despite negative consequences

1 Page: 284 Feedback 1 The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia. 2 Disturbed thought processes R/T tactile hallucinations is important, but is not the priority nursing diagnosis. 3 Ineffective coping R/T powerlessness over alcohol use is important, but is not the priority nursing diagnosis. 4 Ineffective denial R/T continued alcohol use despite negative consequences is important, but is not the priority nursing diagnosis.

20. A nursing instructor is teaching nursing students about cirrhosis of the liver. Which of the following statements about the complications of hepatic encephalopathy should indicate to the nursing instructor that further student teaching is needed? (Select all that apply.) 1. "A diet rich in protein will promote hepatic healing." 2. "This condition results from a rise in serum ammonia, leading to impaired mental functioning." 3. "In this condition, an excessive amount of serous fluid accumulates in the abdominal cavity." 4. "Neomycin and lactulose are used in the treatment of this condition." 5. "This condition is caused by the inability of the liver to convert ammonia to urea."

1 Page: 289 Feedback 1. The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing. The treatment of hepatic encephalopathy requires abstention from alcohol and temporary elimination of protein from the diet. 2. This statement indicates that teaching has been effective. 3. This statement indicates that no further education is required. 4. The instructor should interpret this statement as accurate.

15. A client diagnosed with major depressive episode and substance use disorder has an altered sleep pattern and demands a psychiatrist to prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? 1. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance. 2. Sedative-hypnotics are expensive and have numerous side effects. 3. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. 4. Sedative-hypnotics are known not to be as effective in promoting sleep as antidepressant medications.

1 Page: 291 Feedback 1 The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance. The effects of central nervous system depressants are additive with one another, capable of producing physiological and psychological addiction. 2 These drugs do not have numerous side effects. 3 The drugs do not interfere with REM sleep. 4 These drugs are effective for inducing sleep.

5. A lonely, depressed divorcée has been self-medicating with small amounts of cocaine for the past year. Which term should a nurse use to best describe this individual's situation? 1. Psychological addiction 2. Codependence 3. Substance induced disorder 4. Social induced disorder

1 Page: 294 Feedback 1 The nurse should use the term psychological addiction to best describe the client's situation. A client is considered to be psychologically addicted to a substance when there is an overwhelming desire to use a drug in order to produce pleasure or avoid discomfort. 2 Codependence describes depending on others for decision-making. 3 Substance induced disorders are induced by the use of a drug or substance. 4 Social induced disorders describe using a drug or substance in the presence of others, or socially.

7. A client diagnosed with chronic alcohol addiction is being discharged from an inpatient treatment facility after detoxification. Which client outcome, related to AA, would be most appropriate for a nurse to discuss with the client during discharge teaching? 1. After discharge, the client will immediately attend 90 AA meetings in 90 days. 2. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. 3. After discharge, the client will incorporate family in AA attendance. 4. After discharge, the client will seek appropriate deterrent medications through AA.

1 Page: 307, 312, 314-316 Feedback 1 The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcohol addiction. It accepts alcohol addiction as an illness and promotes total abstinence as the only cure. 2 Relying on a sponsor does not hold the client accountable. 3 Encouraging family attendance at AA meetings does not hold the client accountable. 4 Seeking further deterrent medications does not hold the client accountable.

17. A nurse is assessing a pathological gambler. What would differentiate this client's behaviors from the behaviors of a non-pathological gambler? 1. Pathological gamblers have abnormal levels of neurotransmitters, whereas non-pathological gamblers do not. 2. Pathological gambling occurs more commonly among women, whereas non-pathological gambling occurs more commonly among men. 3. Pathological gambling generally runs an acute course, whereas non-pathological gambling runs a chronic course. 4. Pathological gambling is not related to stress relief, whereas non-pathological gambling is related to stress relief.

1 Page: 330-331 Feedback 1 There is a correlation between pathological gambling and abnormalities in the serotonergic, noradrenergic, and dopaminergic neurotransmitter systems. This is not the case with non-pathological gambling. 2 Pathological gambling occurs more commonly among men not women and generally runs a chronic, not acute course. 3 This statement is inaccurate regarding the pathological gambler. 4 For a pathological gambler, the preoccupation with and impulse to gamble intensifies when the individual is under stress.

3. A 16-year-old client diagnosed with schizophrenia spectrum disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response? 1. "Your child has a chemical imbalance of the brain, which leads to altered perceptions." 2. "Your child's hallucinations are caused by medication interactions." 3. "Your child has too little serotonin in the brain, causing delusions and hallucinations." 4. "Your child's abnormal hormonal changes have precipitated auditory hallucinations."

1 Page: 342-343 Feedback 1 The nurse should explain that a chemical imbalance of the brain leads to altered perceptions. 2 The client hearing voices is experiencing an auditory hallucination, which is not caused by medication. 3 Serotonin excess is thought to cause hallucinations. 4 Abnormal hormonal changes have not precipitated auditory hallucinations.

4. Which client should the nurse anticipate to be most receptive to psychiatric treatment? 1. A Jewish, female social worker. 2. A Baptist, homeless male. 3. A Catholic, black male. 4. A Protestant, Swedish business executive.

1 Page: 4 Feedback 1 The nurse should anticipate that the client of Jewish culture would place a high importance on preventative health care and would consider mental health as equally important to physical health. 2 The homeless client may have difficulty accessing health care and may not place a high emphasis on mental health treatment. 3 Women are more likely to seek treatment for mental health problems than men. 4 This client is not typically as receptive to psychiatric treatment as the client of Jewish culture.

5. A psychiatric nurse intern states, "This client's use of defense mechanisms should be eliminated." Which is a correct evaluation of this nurse's statement? 1. Defense mechanisms can be appropriate responses to stress and need not be eliminated. 2. Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated. 3. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated. 4. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.

1 Page: 7 Feedback 1 The nurse should determine that defense mechanisms can be appropriate during times of stress. 2 Defense mechanisms are not maladaptive attempts of the ego to manage anxiety. 3 Defense mechanisms are a normal part of coping with stress. They are not used by individuals with weak ego integrity. They should not be discouraged and eliminated. 4 Defense mechanisms are normal and are used by all individuals in some way during times of stress; they do not cause disintegration of the ego.

3. A nurse is assessing a set of 15-year-old identical twins who respond very differently to stress. One twin becomes anxious and irritable, and the other withdraws and cries. How should the nurse explain these different stress responses to the parents? 1. Reactions to stress are relative rather than absolute; individual responses to stress vary. 2. It is abnormal for identical twins to react differently to similar stressors. 3. Identical twins should share the same temperament and respond similarly to stress. 4. Environmental influences to stress weigh more heavily than genetic influences.

1 Page: 7 Feedback 1 The nurse should explain to the parents that, although the twins have identical DNA, there are several other factors that affect reactions to stress. 2 It is considered normal for twins to react differently to stress. 3 Identical twins do not necessarily respond similarly to stress, due to differences in temperament and personality. 4 Environmental influences and temperament can affect stress reactions.

24. After a teenager reveals that he is gay, his father responds by beating him. The next morning, the teenager is found hanging in his closet. Which paternal grief responses should a nurse anticipate? Select all that apply. 1. "I can't believe this is happening." 2. "If only I had been more understanding." 3. "How dare he do this to me!" 4. "I'm just going to have to accept that he was gay." 5. "Well, that was a selfish thing to do."

1, 2, 3 Page: 239-240 Feedback 1. Suicide of a family member can induce a whole gamut of feelings in the survivors, including shock. 2. Suicide of a family member can induce a whole gamut of feelings in the survivors, including guilt. 3. Suicide of a family member can induce a whole gamut of feelings in the survivors, including anger. 4. Stating, "I'm just going to have to accept that he was gay," reflects acceptance and understanding. 5. Stating, "Well, that was a selfish thing to do," reflects acceptance and understanding.

16. Which of the following conditions have been known to precipitate delirium in some individuals? (Select all that apply.) 1. Febrile illness 2. Seizures 3. Migraine headaches 4. Herniated brain stem 5. Temporomandibular joint syndrome

1, 2, 3 Page: 249-250 Feedback 1. Delirium most commonly occurs in individuals with serious medical, surgical, or neurological conditions. Some examples of conditions that have been known to precipitate delirium in some individuals include the following: febrile illness. 2. Delirium most commonly occurs in individuals with serious medical, surgical, or neurological conditions. Some examples of conditions that have been known to precipitate delirium in some individuals include the following: seizures. 3. Delirium most commonly occurs in individuals with serious medical, surgical, or neurological conditions. Some examples of conditions that have been known to precipitate delirium in some individuals include the following: migraine headaches. 4. A herniated brain stem would most likely result in death, not delirium. 5. Temporomandibular joint syndrome is marked by limited movement of the joint during chewing, not delirium.

14. Which of the following has SAMHSA described as major dimensions of support for a life of recovery? (Select all that apply) 1. Health 2. Community 3. Home 4. Religious affiliation 5. Purpose

1, 2, 3, 5 Page: 216 Feedback 1. SAMHSA suggests that a life in recovery is supported by four major dimensions, which include health, home, purpose, and community. 2. SAMHSA suggests that a life in recovery is supported by four major dimensions, which include health, home, purpose, and community. 3. SAMHSA suggests that a life in recovery is supported by four major dimensions, which include health, home, purpose, and community. 4. Religious affiliation is not included in the listed dimensions. 5. SAMHSA suggests that a life in recovery is supported by four major dimensions, which include health, home, purpose, and community.

15. A nurse uses the commitments of the Tidal Model of Recovery in psychiatric nursing practice. Which of the following nursing actions reflect the use of the Develop Genuine Curiosity commitment? (Select all that apply.) 1. The nurse expresses interest in the client's story. 2. The nurse asks for clarification of certain points. 3. The nurse encourages the client to speak his own words in his own unique way. 4. The nurse assists the client to unfold the story at his or her own rate. 5. The nurse provides the clients with copies of all documents relevant to care.

1, 2, 4 Page: 219 Feedback 1. Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments, upon which the Tidal Model is based. They include: Value the Voice, Respect the Language, Develop Genuine Curiosity, Become the Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be Transparent. 2. Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments, upon which the Tidal Model is based. They include: Value the Voice, Respect the Language, Develop Genuine Curiosity, Become the Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be Transparent. 3. Encouraging the client to speak his own words in his own unique way is not included in the Tidal Model. 4. Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments, upon which the Tidal Model is based. They include: Value the Voice, Respect the Language, Develop Genuine Curiosity, Become the Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be Transparent. 5. Providing the clients with copies of all documents relevant to care is not included in the Tidal Model.

19. Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with a substance-related disorder? (Select all that apply.) 1. "I am easily manipulated and need to work on this prior to caring for these clients." 2. "Because of my father's alcoholism, I need to examine my attitude toward these clients." 3. "I need to review the side effects of the medications used in the withdrawal process." 4. "I'll need to set boundaries to maintain a therapeutic relationship." 5. "I need to take charge when dealing with clients diagnosed with substance disorders."

1, 2, 4 Page: 312 Feedback 1. The nurse should complete a cognitive process prior to caring for clients diagnosed with substance-abuse disorders. 2. It is important for nurses to identify potential areas of need within their own cognitions that may affect their relationships with clients diagnosed with this problem. 3. This statement does not exemplify the cognitive process that must be completed by a nurse prior to client care. 4. Determining the need to set boundaries is an example of a cognitive process that must be completed by a nurse prior to client care. 5. This statement does not exemplify the cognitive process that must be completed by a nurse prior to client care.

16. A nurse is assessing a client who appears to be experiencing some anxiety during questioning. Which symptoms might the client demonstrate that would indicate anxiety? (Select all that apply.) 1. Fidgeting 2. Laughing inappropriately 3. Palpitations 4. Nail biting 5. Limited attention span

1, 2, 4 Page: 7 Feedback 1. This symptom is a sign of anxiety. 2. This is a symptom that the nurse would expect in a client experiencing anxiety. 3. The nurse would not expect the client to have palpitations. 4. This option indicates anxiety. 5. Limited attention span does not indicate anxiety.

21. A clinic nurse is about to meet with a client diagnosed with a gambling disorder. Which of the following symptoms and/or behaviors is the nurse likely to assess? (Select all that apply.) 1. Stressful situations precipitate gambling behaviors. 2. Anxiety and restlessness can only be relieved by placing a bet. 3. Winning brings about feelings of sexual satisfaction. 4. Gambling is used as a coping strategy. 5. Losing at gambling meets the client's need for self-punishment.

1, 2, 4, 5 Page: 330-331 Feedback 1. In gambling disorder, the preoccupation with and impulse to gamble intensifies when the individual is under stress. 2. Many impulsive gamblers describe a physical sensation of restlessness and anticipation that can only be relieved by placing a bet. 3. Winning brings feelings of special status, power, and omnipotence, not sexual satisfaction. 4. Gambling is used as a coping strategy for dealing with stress and disappointments. 5. The gambler increasingly depends on this activity to cope with disappointments, problems, and negative emotional states.

23. A nursing supervisor is offering an impaired staff member information regarding employee assistance programs. Which of the following facts should the supervisor include? (Select all that apply.) 1. A hotline number will be available in order to call for peer assistance. 2. A verbal contract detailing the method of treatment will be initiated prior to the program. 3. Peer support is provided through regular contact with the impaired nurse. 4. Contact to provide peer support will last for one year. 5. One of the program goals is to intervene early in order to reduce hazards to clients.

1, 3, 5 Page: 322-323 Feedback 1. Most states provide either a hotline number that the impaired nurse may call or phone numbers of peer assistance committee members, which are made available for the same purpose. 2. Typically, a written, not verbal, contract is drawn up, detailing the method of treatment, which may be obtained from various sources, such as employee assistance programs, Alcoholics Anonymous, Narcotics Anonymous, private counseling, or outpatient clinics. 3. Peer support is provided through regular contact with the impaired nurse. 4. Peer support is usually for a period of two years, not one year. 5. The peer assistance programs strive to intervene early, to reduce hazards to clients, and increase prospects for the nurse's recovery.

24. A nursing counselor is about to meet with a client suffering from codependency. Which of the following data would further support the assessment of this dysfunctional behavior? (Select all that apply.) 1. The client has a long history of focusing thoughts and behaviors on other people. 2. The client, as a child, experienced overindulgent and overprotective parents. 3. The client is a people pleaser and does almost anything to gain approval. 4. The client exhibits helpless behaviors but actually feels very competent. 5. The client can achieve a sense of control only through fulfilling the needs of others.

1, 3, 5 Page: 323-324 Feedback 1. The codependent person has a long history of focusing thoughts and behavior on other people and is able to achieve a sense of control only through fulfilling the needs of others. 2. They usually have experienced abuse or emotional neglect as a child. 3. Codependent clients are "people pleasers" and will do almost anything to get the approval of others. 4. They outwardly appear very competent, but actually feel quite needy, helpless, or perhaps nothing at all. 5. Codependent clients achieve a sense of control when they are fulfilling the needs of others.

17. Which of the following medications that have been known to precipitate delirium? (Select all that apply.) 1. Antineoplastic agents 2. H2-receptor antagonists 3. Antihypertensives 4. Corticosteroids 5. Lipid-lowering agents

1234; Page: 250 Feedback 1. Medications that have been known to precipitate delirium include antineoplastic agents. 2. Medications that have been known to precipitate delirium include H2-receptor antagonists (e.g., cimetidine). 3. Medications that have been known to precipitate delirium include antihypertensives. 4. Medications that have been known to precipitate delirium include corticosteroids. 5. There have been no reports of delirium ascribed to the use of lipid-lowering agents.

1. A geriatric nurse is teaching the client's family about the possible cause of delirium. Which statement by the nurse is most accurate? 1. "Taking multiple medications may lead to adverse interactions or toxicity." 2. "Age-related cognitive changes may lead to alterations in mental status." 3. "Lack of rigorous exercise may lead to decreased cerebral blood flow." 4. "Decreased social interaction may lead to profound isolation and psychosis."

1; Page: 249 Feedback 1 The nurse should identify that taking multiple medications that may lead to adverse reactions or toxicity is a risk factor for the development of delirium in older adults. 2 Age-related cognitive changes do not lead to delirium. 3 Lack of vigorous exercise does not lead to delirium. 4 Decreased social interaction does not lead to delirium.

8. Which is the priority focus of recovery models? 1. Empowerment of the health-care team to bring their expertise to decision-making 2. Empowerment of the client to make decisions related to individual health care 3. Empowerment of the family system to provide supportive care 4. Empowerment of the physician to provide appropriate treatments

2 Page: 216 Feedback 1 Empowerment of the health-care team is not the priority focus of the recovery model. 2 The basic concept of a recovery model is empowerment of the client. The recovery model is designed to allow clients primary control over decisions about their own care. 3 Empowerment of the family system is not the priority focus of the recovery model. 4 Empowerment of the physician is not the priority focus of the recovery model.

1. A nursing instructor is teaching about recovery as it applies to mental illness. Which student statement indicates that further teaching is needed? 1. "The goal of recovery is improved health and wellness." 2. "The goal of recovery is expedient, comprehensive behavioral change." 3. "The goal of recovery is the ability to live a self-directed life." 4. "The goal of recovery is the ability to reach full potential."

2 Page: 216 Feedback 1 The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery from mental health disorders and substance use disorders as a process of change through which individuals improve their health and wellness. 2 Change in recovery is not an expedient process. It occurs incrementally over time. 3 SAMHSA defines recovery from mental health disorders and substance use disorders as a process of change through which individuals live a self-directed life. 4 SAMHSA defines recovery from mental health disorders and substance use disorders as a process of change through which individuals strive to reach their full potential.

4. A client diagnosed with alcohol abuse disorder is referred to a residential care facility after discharge. According to SAMHSA, which dimension of recovery is supporting this client? 1. Health 2. Home 3. Purpose 4. Community

2 Page: 216 Feedback 1 The dimension of health is not supporting this client. 2 SAMHSA describes the dimension of home as a stable and safe place to live. 3 The dimension of purpose is not supporting this client. 4 The dimension of community is not supporting this client.

3. A nursing instructor is teaching about the guiding principles of the recovery model, as described by SAMHSA. Which student statement indicates that further teaching is needed? 1. "Recovery occurs via many pathways." 2. "Recovery emerges from strong religious affiliations." 3. "Recovery is supported by peers and allies." 4. "Recovery is culturally based and influenced."

2 Page: 217 Feedback 1 The statement indicates understanding of the recovery model. 2 Recovery emerges from hope but affiliation with any particular religion would have little bearing on the recovery process. 3 This statement indicates that the student has adequate understanding of the recovery model. 4 This statement is accurate regarding the recovery model.

6. A nurse maintains a client's confidentiality, addressed the client appropriately, and does not discriminate based on gender, age, race, or religion. Which guiding principle of recovery has this nurse employed? 1. Recovery is culturally based and influenced. 2. Recovery is based on respect. 3. Recovery involves individual, family, and community strengths and responsibility. 4. Recovery is person-driven.

2 Page: 218 Feedback 1 SAMHSA lists the following as guiding principles for the recovery model: Recovery is culturally based and influenced. 2 SAMHSA lists the following as guiding principles for the recovery model: Recovery is based on respect. 3 SAMHSA lists the following as guiding principles for the recovery model: Recovery involves individual, family, and community strengths and responsibility. 4 SAMHSA lists the following as guiding principles for the recovery model: Recovery is person-driven.

10. A nursing instructor is teaching about components present in the recovery process as described by Andresen and associates that led to the development of the Psychological Recovery Model. Which student statement indicates that further teaching is needed? 1. "A client has a better chance of recovery if he or she truly believes that recovery can occur." 2. "If a client is willing to give the responsibility of treatment to the health-care team, they are likely to recover." 3. "A client who has a positive sense of self and a positive identity is likely to recover." 4. "A client has a better chance of recovery if he or she has purpose and meaning in life."

2 Page: 220 Feedback 1 This statement is true regarding recovery. 2 In examining a number of studies, Andresen and associates identified four components that were consistently evident in the recovery process. These components are hope, responsibility, self and identity, and meaning and purpose. Under responsibility, this model tasks the client, not the health-care team, with taking responsibility for his or her life and well-being. 3 This statement indicates that teaching has been effective. 4 This statement indicates that no further teaching is necessary.

12. A client states, "I have come to the conclusion that this disease has not paralyzed me." The nurse recognizes that this client is in which stage of the Psychological Recovery Model as described by Andresen and associates? 1. Moratorium 2. Awareness 3. Preparation 4. Rebuilding

2 Page: 222 Feedback 1 Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 1: Moratorium. 2 Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 2: Awareness. 3 Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 3: Preparation. 4 Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 4: Rebuilding.

11. A nursing instructor is teaching about suicide in the elderly population. Which information should the instructor include? 1. Elderly people use less lethal means to commit suicide. 2. Although the elderly comprise less than 13 percent of the population, they account for 15 percent of all suicides. 3. Suicide is the second leading cause of death among the elderly. 4. It is normal for elderly individuals to express a desire to die, because they have come to terms with their mortality.

2 Page: 234 Feedback 1 The elderly do not necessarily use less lethal means of committing suicide. 2 Although the elderly comprise less than 13 percent of the population, they account for 15 percent of all suicides. 3 Suicide is not the second leading cause of death among the elderly. 4 An expressed desire to die is not normal in any age group.

10. After years of dialysis, an 84-year-old states, "I'm exhausted, depressed, and done with these attempts to keep me alive." Which question should the nurse ask the spouse when preparing a discharge plan of care? 1. "Have there been any changes in appetite or sleep?" 2. "How often is your spouse left alone?" 3. "Has your spouse been following a diet and exercise program consistently?" 4. "How would you characterize your relationship with your spouse?"

2 Page: 237 Feedback 1 Changes in appetite or sleep do not accurately indicate risk for suicide. 2 This client has many risk factors for suicide. The client should have increased supervision to decrease likelihood of self-harm. 3 Asking about diet and exercise do not assess risk for suicide. 4 Asking about the client's relationship with his spouse does not accurately assess the risk for suicide.

5. A nurse admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this client's safety upon discharge? 1. Provide a 6-month supply of Elavil to ensure long-term compliance. 2. Provide a 3-day supply of Elavil with refills contingent on follow-up appointments. 3. Provide a pill dispenser as a memory aid. 4. Provide education regarding the avoidance of foods containing tyramine.

2 Page: 237 Feedback 1 This amount of medication may be enough for the client to overdose. 2 The health-care provider should provide no more than a 3-day supply of Elavil with refills contingent on follow-up appointments as an appropriate intervention to maintain the client's safety. Tricyclic antidepressants have a narrow therapeutic range and can be used in overdose to commit suicide. Distributing limited amounts of the medication decreases this potential. In addition, clients may gain energy to carry out a suicide once they begin to have more energy from taking the antidepressants. 3 This option would not prevent the client from committing suicide. 4 This option does not prevent suicide.

16. Which is a correctly written, appropriate outcome for a client with a history of suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating self? 1. The client will not physically harm self. 2. The client will express three positive self-attributes by day four. 3. The client will reveal a suicide plan. 4. The client will establish a trusting relationship.

2 Page: 237 Feedback 1 This outcome may take time for the client to commit to. 2 Although the client has a history of suicide attempts, the current problem is isolative behaviors based on low self-esteem. Outcomes should be client-centered, specific, realistic, and measurable and contain a time frame. 3 This outcome may be a big step for the client. 4 This outcome may not be realistic right away for the client.

9. A stockbroker commits suicide after being convicted of insider trading. In speaking with the family, which statement by the nurse demonstrates accurate and appropriate sharing of information? 1. "Your grieving will subside within 1 year; until then I recommend antidepressants." 2. "Support groups are available specifically for survivors of suicide, and I would be glad to help you locate one in this area." 3. "The only way to deal effectively with this kind of grief is to write a letter to the brokerage firm to express your anger with them." 4. "Since stigmatization often occurs in these situations, it would be best if you avoid discussing the suicide with anyone."

2 Page: 240 Feedback 1 This statement is not therapeutic for the family or helpful. 2 Bereavement following suicide is complicated by the complex psychological impact of the act on those close to the victim. Support groups for survivors can provide a meaningful resource for grief work. 3 This statement provides inaccurate information to the family. 4 This statement is inaccurate and not therapeutic to the family.

11. A client with a history of cerebrovascular accident is brought to an emergency department experiencing memory problems, confusion, and disorientation. Based on this client's assessment data, which diagnosis would the nurse expect the physician to assign? 1. Delirium due to adverse effects of cardiac medications 2. Vascular neurocognitive disorder 3. Altered thought processes 4. Alzheimer's disease

2 Page: 250, 252-253 Feedback 1 It is not known whether or not the client is taking cardiac medications. 2 The nurse should expect that the client will be diagnosed with vascular NCD, which is caused by significant cerebrovascular disease. Vascular NCD often has an abrupt onset. Progression of this disease often occurs in a fluctuating pattern. 3 Based on symptoms and progression of the disease, the physician would not diagnose altered thought process. 4 The physician would not likely diagnose Alzheimer's disease.

15. Which statement accurately differentiates NCD from pseudodementia (depression)? 1. NCD has a rapid onset, whereas pseudodementia does not. 2. NCD symptoms include disorientation to time and place, and pseudodementia does not. 3. NCD symptoms improve as the day progresses, but symptoms of pseudodementia worsen. 4. NCD causes decreased appetite, whereas pseudodementia does not.

2 Page: 259 Feedback 1 NCD has a slow progression of symptoms, whereas pseudodementia has a rapid progression of symptoms. 2 NCD symptoms include disorientation to time and place, and pseudodementia does not. 3 NCD symptoms' severity worsens as the day progresses, whereas in pseudodementia, symptoms improve as the day progresses. 4 In NCD the appetite remains unchanged, whereas in pseudodementia, the appetite diminishes.

10. A client diagnosed with major NCD is exhibiting behavioral problems on a daily basis. At change of shift, the client's behavior escalates from pacing to screaming and flailing. Which action should be a nursing priority? 1. Consult the psychologist regarding behavior-modification techniques. 2. Medicate the client with prn antianxiety medications. 3. Assess environmental triggers and potential unmet needs. 4. Anticipate the behavior and restrain when pacing begins.

2 Page: 265 Feedback 1 Consulting the psychologist is not the priority, because it does not keep the client safe. 2 The priority nursing action is to first medicate the client to avoid injury to self or others. 3 It is important to assess environmental triggers and potential unmet needs in order to address these problems in the future, but interventions to ensure safety must take priority. Because of the cognitive decline experienced in clients diagnosed with this disorder, communication skills and orientation may limit assessment and teaching interventions. 4 Restraining the client may make behavioral problems worse.

18. A nursing instructor is teaching about the impaired nurse and the consequences of this impairment. Which statement by a student indicates that further instruction is needed? 1. "The state board of nursing must be notified with factual documentation of impairment." 2. "All state boards of nursing have passed laws that, under any circumstances, do not allow impaired nurses to practice." 3. "Many state boards of nursing require an impaired nurse to successfully complete counseling treatment programs prior to a return to work." 4. "After a return to practice, a recovering nurse may be closely monitored for several years."

2 Page: 283-284 Feedback 1 This is an accurate statement regarding impaired nurses. 2 Several state boards of nursing have passed diversionary laws that allow impaired nurses to avoid disciplinary action by agreeing to seek treatment. This may require successful completion of inpatient, outpatient, group, or individual counseling treatment program(s); evidence of regular attendance at nurse support groups or 12-step program; random negative drug screens; and employment or volunteer activities during the suspension period. 3 This statement does not indicate that further education is required. 4 This statement indicates that teaching has been effective.

2. A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance addiction? 1. Narcotic pain medication is contraindicated for all clients with active substance use disorders. 2. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to analgesics and require increased doses to achieve effective pain control. 3. There is no need to assess the client for substance addiction. There is an obvious PCA malfunction, because these clients have a higher pain tolerance. 4. The client is experiencing alcohol withdrawal symptoms and needs accurate assessment.

2 Page: 287 Feedback 1 Narcotic pain medication should never be held because a client has a substance abuse disorder. 2 The nurse should assess the client for substance addiction, because clients who are addicted to alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. Cross-tolerance is exhibited when one drug results in a lessened response to another drug. 3 The client should be assessed for a substance abuse disorder as needed, so that proper follow up can be arranged for the client. 4 In this scenario, the client is not exhibiting signs of substance abuse withdrawal.

8. A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 48 hours. When the nurse reports to the ED physician, which client symptom should be the nurse's first priority? 1. Hearing and visual impairment 2. Blood pressure of 180/100 mm Hg 3. Mood rating of 2/10 on numeric scale 4. Dehydration

2 Page: 291 Feedback 1 Hearing and visual impairment are not life threatening and do not indicate alcohol withdrawal. 2 The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal syndrome and should promptly report this finding to the physician. Complications associated with alcohol withdrawal syndrome may progress to alcohol withdrawal delirium in about the second or third day following cessation of prolonged alcohol use. 3 A mood rating of 2/10 on numeric scale is not life threatening and does not indicate alcohol withdrawal. 4 Dehydration is not life threatening and does not indicate alcohol withdrawal.

14. A nurse is reviewing the stat laboratory data of a client in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? 1. 50 mg/dL 2. 100 mg/dL 3. 250 mg/dL 4. 300 mg/dL

2 Page: 291 Feedback 1 Intoxication would not occur at this blood alcohol level. 2 The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. 3 Blood alcohol would have to be higher for intoxication to occur. 4 While the client would be intoxicated, this is not the minimum level at which intoxication would occur.

14. According to Maslow's hierarchy of needs, which situation on an inpatient psychiatric unit would require priority intervention by a nurse? 1. A client rudely complaining about limited visiting hours 2. A client exhibiting aggressive behavior toward another client 3. A client stating that no one cares 4. A client verbalizing feelings of failure

2 Page: 3 Feedback 1 Clients who complain are struggling with higher-level needs, such as the need for love and belonging or the need for self-esteem. 2 The nurse should immediately intervene when a client exhibits aggressive behavior toward another client. Safety and security are considered lower-level needs according to Maslow's hierarchy of needs and must be fulfilled before other higher-level needs can be met. 3 Clients who state that no one cares are struggling with higher-level needs such as the need for love and belonging or the need for self-esteem. 4 Clients who have feelings of failure are struggling with higher-level needs, such as the need for love and belonging or the need for self-esteem.

2. At what point should the nurse determine that a client is at risk for developing a mental illness? 1. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria. 2. When maladaptive responses to stress are coupled with interference in daily functioning. 3. When a client communicates significant distress. 4. When a client uses defense mechanisms as ego protection.

2 Page: 3 Feedback 1 The client with a mental illness would have symptoms that reflect the DSM-5. 2 The nurse should determine that the client is at risk for mental illness when responses to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed with a mental illness, daily functioning must be significantly impaired. 3 The client's ability to communicate distress would be considered a positive attribute. 4 The use of defense mechanisms does not indicate that the client is at risk for mental illness.

1. A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety? 1. Assess for medication nonadherence. 2. Note escalating behaviors and intervene immediately. 3. Interpret attempts at communication. 4. Assess triggers for bizarre, inappropriate behaviors.

2 Page: 350-351 Feedback 1 Assessing for medication nonadherence does not indicate that the client's safety may be at risk. 2 The nurse should note escalating behaviors and intervene immediately, to maintain this client's safety. Early intervention may prevent an aggressive response and keep the client and others safe. 3 Interpreting attempts at communication does not indicate that the client's safety may be at risk. 4 Assessing triggers for bizarre, inappropriate behaviors does not indicate that the client's safety may be at risk.

10. Which nursing statement regarding the concept of psychosis is most accurate? 1. Individuals experiencing psychoses are aware that their behaviors are maladaptive. 2. Individuals experiencing psychoses experience little distress. 3. Individuals experiencing psychoses are aware of experiencing psychological problems. 4. Individuals experiencing psychoses are based in reality.

2 Page: 6 Feedback 1 The client with psychosis is unaware that his or her behavior is maladaptive. 2 The nurse should understand that the client with psychosis experiences little distress owing to his or her lack of awareness of reality. 3 The client with psychosis is unaware he or she has a psychological problem. 4 The client experiencing psychosis has a lack of awareness of reality.

9. Which nursing statement about the concept of neurosis is most accurate? 1. An individual experiencing neurosis is unaware that he or she is experiencing distress. 2. An individual experiencing neurosis feels helpless to change his or her situation. 3. An individual experiencing neurosis is aware of the psychological causes of his or her behavior. 4. An individual experiencing neurosis has a loss of contact with reality.

2 Page: 9 Feedback 1 The client is aware that he or she is experiencing distress. 2 The client feels helpless to change his or her situation. 3 The client is unaware of the psychological causes of the distress. 4 The client experiences no loss of contact with reality.

22. A nursing supervisor is about to meet with a staff nurse suspected of diverting client medications. Which of the following assessment data would lead the supervisor to suspect that the staff nurse is impaired? (Select all that apply.) 1. The staff nurse is frequently absent from work. 2. The staff nurse experiences mood swings. 3. The staff nurse makes elaborate excuses for behavior. 4. The staff nurse frequently uses the restroom. 5. The staff nurse has a flushed face.

2, 3, 4, 5 Page: 322-323 Feedback 1. There may be high absenteeism if the person's source is outside the work area. 2. Mood swings can be a sign of substance abuse. 3. The impaired nurse may make elaborate excuses for behavior. 4. The impaired nurse will frequently use the restroom. 5. A flushed face is a sign of drug use.

12. Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief? 1. "If only we could have tried again, things might have worked out." 2. "I am so mad that the children and I had to put up with him as long as we did." 3. "Yes, it was a difficult relationship, but I think I have learned from the experience." 4. "I still don't have any appetite and continue to lose weight."

3 Page: 10 Feedback 1 This statement indicates denial. 2 This statement indicates anger. 3 The nurse should evaluate that the client is in the acceptance stage of grief because during this stage of the grief process, the client would be able to focus on the reality of the loss and its meaning in relation to life. 4 This statement indicates prolonged grieving.

7. A nurse on an inpatient unit helps a client understand the significance of treatments, and provides the client with copies of all documents related to the plan of care. This nurse is employing which commitment in the "Tidal Model of Recovery?" 1. Know that Change Is Constant 2. Reveal Personal Wisdom 3. Be Transparent 4. Give the Gift of Time

3 Page: 218 Feedback 1 Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments upon which the Tidal Model is based. They include: Know That Change Is Constant. 2 Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments upon which the Tidal Model is based. They include: Reveal Personal Wisdom. 3 Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments upon which the Tidal Model is based. They include: Be Transparent. 4 Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments upon which the Tidal Model is based. They include: Give the Gift of Time.

18. A nurse is caring for four clients diagnosed with major depressive disorder. When considering each client's belief system, the nurse should conclude which client would potentially be at highest risk for suicide? 1. Roman Catholic 2. Protestant 3. Atheist 4. Muslim

3 Page: 231 Feedback 1 Depressed men and women who consider themselves affiliated with a religion are less likely to attempt suicide than their nonreligious counterparts because religions teach that suicide is a sin. 2 Depressed men and women who consider themselves affiliated with a religion are less likely to attempt suicide than their nonreligious counterparts because religions teach that suicide is a sin. 3 An atheist does not believe in punishment for suicide by a higher power. 4 Depressed men and women who consider themselves affiliated with a religion are less likely to attempt suicide than their nonreligious counterparts because religions teach that suicide is a sin.

22. A client is newly admitted to an inpatient psychiatric unit. Which of the following is most critical to assess when determining risk for suicide? 1. Family history of depression 2. The client's orientation to reality 3. The client's history of suicide attempts 4. Family support systems

3 Page: 232 Feedback 1 Family history of depression is not critical to determining risk for suicide. 2 Client's orientation to reality not critical to determining risk for suicide. 3 A history of suicide attempts places a client at a higher risk for current suicide behaviors. Knowing this specific data will alert the nurse to the client's risk. Of those who commit suicide, 50-80 percent had a previous attempt. 4 Family support systems are not critical to determining risk for suicide.

3. A client diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time? 1. Obtaining an order for locked seclusion until client is no longer suicidal 2. Conducting 15-minute checks to ensure safety 3. Placing the client on one-to-one observation while monitoring suicidal ideations 4. Encouraging client to express feelings related to suicide

3 Page: 236 Feedback 1 Seclusion may be excessive for this client. 2 Checks every 15 minutes would be inadequate for this client. 3 The nurse's priority intervention when a client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideation. 4 The client's physical safety is the priority.

14. A new nursing graduate asks the psychiatric nurse manager how to best classify suicide. Which is the nurse manager's best reply? 1. "Suicide is a DSM-5 diagnosis." 2. "Suicide is a mental disorder." 3. "Suicide is a behavior." 4. "Suicide is an antisocial affliction."

3 Page: 236 Feedback 1 Suicide is not a diagnosis. 2 Suicide is not a disorder. 3 Suicide is a behavior. 4 Suicide is not an affliction.

21. Which client data indicates that a suicidal client is participating in a plan for safety? 1. Compliance with antidepressant therapy 2. A mood rating of 9/10 3. Disclosing a plan for suicide to staff 4. Expressing feelings of hopelessness to nurse

3 Page: 238-239 Feedback 1 Compliance with antidepressant therapy does not indicate the client participating in a plan for safety. 2 A mood rating of 9/10 does not indicate the client participating in a plan for safety. 3 A degree of the responsibility for the suicidal client's safety is given to the client. When a client shares with staff a plan for suicide, the client is participating in a plan for safety by communicating thoughts of self-harm that would initiate interventions to prevent suicide. 4 Expressing feelings of hopelessness do not indicate the client participating in a plan for safety.

20. A client is newly committed to an inpatient psychiatric unit. Which nursing intervention best lowers this client's risk for suicide? 1. Encouraging participation in the milieu to promote hope 2. Developing a strong personal relationship with the client 3. Observing the client at intervals determined by assessed data 4. Encouraging and redirecting the client to concentrate on happier times

3 Page: 238-239 Feedback 1 Encouraging participation does not best lower the client's risk for suicide. 2 Developing a personal relationship with the client does not best lower the client's risk for suicide. 3 The nurse should observe the actively suicidal client continuously for the first hour after admission. After a full assessment the treatment team will determine the observation status of the client. Observation of the client allows the nurse to interrupt any observed suicidal behaviors. 4 Encouraging and redirecting the client does not best lower the client's risk for suicide.

13. A client diagnosed with NCD is disoriented, ataxic and wanders. Which is the priority nursing diagnosis? 1. Disturbed thought processes 2. Self-care deficit 3. Risk for trauma 4. Altered health-care maintenance

3 Page: 251 Feedback 1 Disturbed thought process is an important diagnosis, but safety is the priority. 2 Self-care deficit is an important diagnosis, but safety is the priority. 3 The priority nursing diagnosis for this client is risk for injury. The client who is ataxic suffers from motor coordination deficits and is at an increased risk for falls. Clients that wander are at a higher risk for injury. 4 Altered health-care maintenance is an important diagnosis, but safety is the priority.

14. Which statement accurately differentiates mild NCD from major NCD? 1. Major NCD involves disorientation that develops suddenly, whereas mild NCD develops more slowly. 2. Major NCD involves impairment of abstract thinking and judgment, whereas mild NCD does not. 3. Major NCD criteria requires substantial cognitive decline from a previous level of performance, and mild NCD requires modest decline. 4. Major NCD criteria requires decline from a previous level of performance in three of the listed domains, and mild NCD requires only one.

3 Page: 251 Feedback 1 The progression of the disorder is not a criterion for determining the severity of an NCD. 2 Abstract thinking and judgment can be affected in both mild NCD and major NCD. 3 Major NCD criteria requires substantial cognitive decline, and mild NCD requires modest decline. 4 Both major and mild NCD classifications require decline from a previous level of performance in only one of the listed domains.

4. A client is diagnosed in stage 7 of AD. To address the client's symptoms, which nursing intervention should take priority? 1. Improve cognitive status by encouraging involvement in social activities. 2. Decrease social isolation by providing group therapies. 3. Promote dignity by providing comfort, safety, and self-care measures. 4. Facilitate communication by providing assistive devices.

3 Page: 253 Feedback 1 Encouraging involvement in social activities does not address the client's symptoms. 2 Decreasing social isolation does not address the client's symptoms. 3 The most appropriate intervention in the seventh stage of AD is to promote the client's dignity by providing comfort, safety, and self-care measures. Stage 7 is characterized by severe cognitive decline in which the client is unable to recognize family members and is most commonly bedfast and aphasic. 4 Facilitating communication does not address the client's symptoms.

8. After one week of continuous mental confusion, an older African American client is admitted with a preliminary diagnosis of AD. What should cause the nurse to question this diagnosis? 1. AD does not typically occur in African American clients. 2. The symptoms presented are more indicative of Parkinsonism. 3. AD does not develop suddenly. 4. There has been no T3- or T4-level evaluation ordered.

3 Page: 259 Feedback 1 This option does not accurately reflect AD. 2 Presentation mirroring Parkinson's disease does not accurately reflect AD. 3 The nurse should recognize that AD does not develop suddenly and should question this diagnosis. The onset of AD symptoms is slow and insidious. The disease is generally progressive and deteriorating. 4 This option would not cause the nurse to question the diagnosis.

7. A client diagnosed with AD exhibits progressive memory loss, diminished cognitive functioning, and verbal aggression upon experiencing frustration. Which nursing intervention is most appropriate? 1. Organize a group activity to present reality. 2. Minimize environmental lighting. 3. Schedule structured daily routines. 4. Explain the consequences for aggressive behaviors.

3 Page: 266 Feedback 1 Organizing a group activity to present reality is not likely to reduce verbal aggression. 2 Minimizing environmental lighting will not likely reduce verbal aggression. 3 The most appropriate nursing intervention for this client is to schedule structured daily routines. A structured routine will reduce frustration and thereby reduce verbal aggression. 4 Explaining the consequences for aggressive behaviors will not likely reduce verbal aggression.

3. On the first day of a client's alcohol detoxification, which nursing intervention should take priority? 1. Strongly encourage the client to attend 90 Alcoholics Anonymous (AA) meetings in 90 days. 2. Educate the client about the biopsychosocial consequences of alcohol abuse. 3. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. 4. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

3 Page: 284 Feedback 1 Encouraging AA meetings is important, but the administration of medication to prevent alcohol withdrawal takes priority due to client safety. 2 Education is important, but the administration of medication to prevent alcohol withdrawal takes priority due to client safety. 3 The priority nursing intervention for this client should be to administer ordered chlordiazepoxide in a dosage according to protocol. Chlordiazepoxide is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal to reduce life-threatening complications. 4 Vitamin B1 administration is important, but the administration of medication to prevent alcohol withdrawal takes priority due to client safety.

13. A nurse is performing a mental health assessment on an adult client. According to Maslow's hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health? 1. Maintaining a long-term, faithful, intimate relationship 2. Achieving a sense of self-confidence 3. Possessing a feeling of self-fulfillment and realizing full potential 4. Developing a sense of purpose and the ability to direct activities

3 Page: 3 Feedback 1 This option is not the highest level on Maslow's hierarchy of needs. 2 While this option is important, it is not the highest level on Maslow's hierarchy of needs. 3 The nurse should identify that the client who possesses a feeling of self-fulfillment and realizes his or her full potential has achieved self-actualization, the highest level on Maslow's hierarchy of needs. 4 This option is important for the development of the client, but is not the most important on Maslow's hierarchy of needs.

11. A client presents with symptoms of alcohol withdrawal and states, "I haven't eaten in three days." A nurse's assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry mucous membranes and poor skin turgor. What should be the priority nursing diagnosis? 1. Knowledge deficit 2. Fluid volume excess 3. Imbalanced nutrition: less than body requirements 4. Ineffective individual coping

3 Page: 312 Feedback 1 Knowledge deficit is incorrect because it does not address the client's statement regarding lack of nutritional intake for three days. 2 Fluid volume excess is incorrect because it does not address the client's statement regarding lack of nutritional intake for three days. 3 The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition, as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods. 4 Ineffective individual coping is incorrect because it does not address the client's statement regarding lack of nutritional intake for three days.

12. A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "His problems at work are my fault." Which is the appropriate nursing response? 1. "Why do you assume responsibility for his behaviors?" 2. "I think you should start to confront his behavior." 3. "Your husband needs to deal with the consequences of his drinking." 4. "Do you understand what the term enabler means?"

3 Page: 323-324 Feedback 1 Stating, "Why do you assume responsibility for his behaviors?" may come across as confrontational, and may cause the client's wife to avoid interaction with the nurse. 2 Stating, "I think you should start to confront his behavior." may come across as confrontational, and may cause the client's wife to avoid interaction with the nurse. 3 The appropriate nursing response is to use confrontation with caring. The nurse should understand that the client's wife may be in denial and enabling the husband's behavior. Codependency is a typical behavior of spouses of alcoholics. Partners of clients with substance addiction must come to realize that the only behavior they can control is their own. 4 Stating, "Do you understand what the term enabler means?" may come across as confrontational, and may cause the client's wife to avoid interaction with the nurse.

4. Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia spectrum disorder, tells them that voices command him to harm others. Which is the appropriate nursing response? 1. "Tell him to stop discussing the voices." 2. "Ignore what he is saying, while attempting to discover the underlying cause." 3. "Focus on the feelings generated by the hallucinations and present reality." 4. "Present objective evidence that the voices are not real."

3 Page: 342-343 Feedback 1 This option could cause the client to shut down. 2 The client should not be ignored, but should be encouraged to discuss what is occurring. 3 The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should accept that their child is experiencing the hallucination but should not reinforce this unreal sensory perception. 4 This option would not be appropriate in the care of the schizophrenic client.

2. A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse's teaching? 1. The side effects of medications 2. Deep breathing techniques to decrease stress 3. How to make eye contact when communicating 4. How to be a leader

3 Page: 365 Feedback 1 Teaching the side effects of medication does not help the client obtain better social skills. 2 Teaching deep breathing exercises does not help the client obtain better social skills. 3 The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients to communicate needs and to establish relationships. 4 Teaching leadership skills do not help the client obtain better social skills.

15. How would a nurse best complete the new DSM-5 definition of a mental disorder? "A health condition characterized by significant dysfunction in an individual's cognitions, or behaviors that reflect a disturbance in ..." which of the following? 1. Psychosocial, biological, or developmental process underlying mental functioning 2. Psychological, cognitive, or developmental process underlying mental functioning 3. Psychological, biological, or developmental process underlying mental functioning 4. Psychological, biological, or psychosocial process underlying mental functioning

3 Page: 4 Feedback 1 This option in not part of the DSM-5 definition of a mental disorder. 2 This option does not define the DSM-5's mental disorder definition. 3 The new DSM-5 definition of a mental disorder is "A health condition characterized by significant dysfunction in an individual's cognitions, or behaviors that reflect a disturbance in the psychological, biological, or developmental process underlying mental functioning." 4 This option is incorrect, because it does not meet the definition set by the DSM-5 for mental health disorders.

7. An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee? 1. The employee assertively confronts the boss. 2. The employee leaves the staff meeting to work out in the gym. 3. The employee criticizes a coworker. 4. The employee takes the boss out to lunch.

3 Page: 7 Feedback 1 Confronting others is not a behavior consistent with displacement. 2 Leaving the staff meeting is not a behavior consistent with displacement. 3 The nurse should expect that the client using the defense mechanism displacement would criticize a coworker after being confronted by the boss. 4 Taking the boss out to lunch is not a behavior consistent with displacement.

8. A fourth-grade boy teases and makes jokes about a cute girl in his class. This behavior should be identified by a nurse as indicative of which defense mechanism? 1. Displacement 2. Projection 3. Reaction formation 4. Sublimation

3 Page: 7 Feedback 1 Displacement refers to transferring feelings from one target to another. 2 Projection refers to the attribution of unacceptable feelings or behaviors to another person. 3 The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors. 4 Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities.

6. During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." Which is the nurse's best response? 1. "It is just a routine part of our assessment. All clients are asked these same questions." 2. "Why are you concerned about these types of questions?" 3. "Psychological factors, like excessive stress, have been found to affect medical conditions." 4. "We can skip these questions, if you like. It isn't imperative that we complete this section."

3 Page: 9 Feedback 1 This statement is not therapeutic to the client. 2 This statement is not therapeutic and may anger the client further. 3 The nurse should attempt to educate the client on the negative effects of excessive stress on medical conditions. 4 It is not appropriate to skip physiological and psychosocial questions, as this would lead to an inaccurate assessment.

4. A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurse's priority at this time? 1. Give the client off-unit privileges as positive reinforcement. 2. Encourage the client to share mood improvement in group. 3. Increase frequency of client observation. 4. Request that the psychiatrist reevaluate the current medication protocol.

3; Page: 236 Feedback 1 The client should not be given off-unit privileges, as this could be unsafe. 2 Group involvement is important, but client safety must take priority. 3 The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behaviors prior to attaining the full therapeutic effect of the antidepressant medication. 4 Medication can be reevaluated after client safety has been established.

1. A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention and the rationale for this action? 1. Administering lorazepam (Ativan) prn, because the client is angry about the discovery of the note 2. Establishing room restrictions, because the client's threat is an attempt to manipulate the staff 3. Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide 4. Calling an emergency treatment team meeting, because the client's threat must be addressed

3; Page: 236 Feedback 1 This action would not be appropriate and could be considered a restraint. 2 Establishing room restrictions does not keep the client safe in the immediate situation. 3 The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. The appropriate nursing diagnosis for this client would be risk for suicide. 4 The client's immediate safety is a priority.

16. A client diagnosed with a gambling disorder asks the nurse about medications that may be ordered by the client's physician to treat this disorder. The nurse would give the client information on which medications? 1. Escitalopram (Lexapro) and clozapine (Clozaril) 2. Citalopram (Celexa) and olanzapine (Zyprexa) 3. Lithium carbonate (Lithobid) and sertraline (Zoloft) 4. Naltrexone (ReVia) and ziprasidone (Geodon)

3; Page: 332 Feedback 1 Escitalopram (Lexapro) and clozapine (Clozaril) would not effectively treat this client. 2 Citalopram (Celexa) and olanzapine (Zyprexa) are not treatments of choice for this disorder. 3 Lithium carbonate (Lithobid) and sertraline (Zoloft) have been used successfully in the treatment of pathological gambling as a form of obsessive-compulsive disorder. 4 Naltrexone (ReVia) and ziprasidone (Geodon) would not appropriately treat this client.

2. Which situation presents an example of the basic concept of a recovery model? 1. The client's family is encouraged to make decisions in order to facilitate discharge. 2. A social worker, discovering the client's income, changes the client's discharge placement. 3. A psychiatrist prescribes an antipsychotic drug based on observed symptoms. 4. A client diagnosed with schizophrenia schedules follow-up appointments and group therapy.

4 Page: 216 Feedback 1 The client's family making decisions for the client does not show empowerment of the consumer. 2 The social worker making decisions for the client does not show empowerment of the consumer. 3 The psychiatrist prescribing medication is not an example of empowerment by the consumer. 4 The basic concept of a recovery model is empowerment of the consumer. The recovery model is designed to allow consumers primary control over decisions about their own care.

9. A client experiences an exacerbation of psychiatric symptoms to the point of threatening self-harm. Which action step of the Wellness Recovery Action Plan (WRAP) model should be employed, and what action reflects this step? 1. Step 3: Triggers that cause distress or discomfort are listed. 2. Step 4: Signs indicating relapse are identified and plans for responding are developed. 3. Step 5: A specific plan to help with symptoms is formulated. 4. Step 6: Following client-designed plan, caregivers now become decision-makers.

4 Page: 221 Feedback 1 The WRAP recovery model is a step-wise process through which an individual is able to monitor and manage distressing symptoms that occur in daily life. The six steps include: Step 3. Triggers. 2 The WRAP recovery model is a step-wise process through which an individual is able to monitor and manage distressing symptoms that occur in daily life. The six steps include: Step 4. Early Warning Signs. 3 The WRAP recovery model is a step-wise process through which an individual is able to monitor and manage distressing symptoms that occur in daily life. The six steps include: Step 5. Things Are Breaking Down or Getting Worse. 4 The WRAP recovery model is a step-wise process through which an individual is able to monitor and manage distressing symptoms that occur in daily life. The six steps include: In step 6 (Crisis Planning), clients can no longer care for themselves, make independent decisions, or keep themselves safe. Caregivers take an active role in this step on behalf of the client and implement the plan that the client has previously developed.

17. A nursing instructor is teaching about suicide. Which student statement indicates that learning has occurred? 1. "Suicidal threats and gestures should be considered manipulative and/or attention-seeking." 2. "Suicide is the act of a psychotic person." 3. "All suicidal individuals are mentally ill." 4. "Between 50 and 80 percent of all people who kill themselves have a history of a previous attempt."

4 Page: 230-232 Feedback 1 This statement is inaccurate regarding suicide. 2 This statement is untrue regarding suicide. 3 This statement is a myth about suicide. 4 It is a fact that between 50 and 80 percent of all people who kill themselves have a history with a previous attempt.

8. The family of a suicidal client is very supportive and requests more facts related to caring for their family member after discharge. Which information should the nurse provide? 1. Address only serious suicide threats to avoid the possibility of secondary gain. 2. Promote trust by verbalizing a promise to keep suicide attempt information within the family. 3. Offer a private environment to provide needed time alone at least once a day. 4. Be available to actively listen, support, and accept feelings.

4 Page: 236 Feedback 1 Addressing only serious suicide threats would not be helpful to the client. 2 Keeping suicide attempts a secret in the family does not help the client. 3 Providing alone time does not help the client. 4 Being available to actively listen, support, and accept feelings increases the potential that a client would confide suicidal ideations to family members.

15. A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first? 1. Communicate therapeutically. 2. Observe the client. 3. Provide a hazard-free environment. 4. Assess suicide risk.

4 Page: 236 Feedback 1 After assessing suicide risk, the nurse can communicate therapeutically. 2 After assessing suicide risk, the nurse can observe the client. 3 After assessing suicide risk, the nurse can provide a hazard-free environment. 4 Assessment is the first step of the nursing process to gain needed information to determine further appropriate interventions. Suicide risk assessment should always be the first step taken when working with depressed or suicidal patients.

7. The treatment team is making a discharge decision regarding a previously suicidal client. Which client assessment information should a nurse recognize as contributing to the team's decision? 1. No previous admissions for major depressive disorder 2. Vital signs stable; no psychosis noted 3. Able to comply with medication regimen; able to problem-solve life issues 4. Able to participate in a plan for safety; family agrees to constant observation

4 Page: 236 Feedback 1 History of admissions does not focus on suicide prevention. 2 Assessment of vital signs does not focus on suicide prevention. 3 Compliance with medication regimen does not focus on suicide prevention. 4 Participation in a plan of safety and constant family observation will decrease the risk for self-harm.

6. During a one-to-one session with a client, the client states, "Nothing will ever get better," and "Nobody can help me." Which nursing diagnosis is most appropriate for a nurse to assign to this client at this time? 1. Powerlessness R/T altered mood AEB client statements 2. Risk for injury R/T altered mood AEB client statements 3. Risk for suicide R/T altered mood AEB client statements 4. Hopelessness R/T altered mood AEB client statements

4 Page: 236 Feedback 1 The client is experiencing hopelessness. This diagnosis would be inappropriate. 2 Risk for injury has not been identified. 3 Risk for suicide has not been identified. 4 The client's statements indicate the problem of hopelessness. Prior to assigning either risk for injury or risk for suicide, a further evaluation of the client's suicidal ideations and intent would be necessary.

13. A suicidal client says to a nurse, "There's nothing to live for anymore." Which is the most appropriate nursing reply? 1. "Why don't you consider doing volunteer work in a homeless shelter?" 2. "Let's discuss the negative aspects of your life." 3. "Things will look better in the morning." 4. "It sounds like you are feeling pretty hopeless."

4 Page: 236 Feedback 1 This question does not help the client open up about feelings. 2 This statement does not help the client discuss feelings. 3 This statement may be degrading to the client's feelings. 4 This statement verbalizes the client's implied feelings and allows him or her to validate and explore them. This statement also shows empathy toward the client and may help them open up and discuss their feelings.

5. Which is the reason for the proliferation of the diagnosis of NCDs? 1. Increased numbers of neurotransmitters have been implicated in the proliferation of NCD. 2. Similar symptoms of NCD and depression lead to misdiagnoses, increasing numbers of NCD. 3. Societal stress contributes to the increase in this diagnosis. 4. More people now survive into the high-risk period for neurocognitive disorders.

4 Page: 250 Feedback 1 The increased number of neurotransmitters is not the reason for the proliferation of the diagnosis of NCDs 2 Similar symptoms of NCD and depression does not lead to increasing numbers of NCD. 3 Societal stress does not contribute to the increase in this diagnosis. 4 The proliferation of NCD has occurred because more people now survive into the high-risk period for neurocognitive disorder, which is middle age and beyond. Previously, many more people died in their 50s, 60s, and early 70s.

3. A client diagnosed with Alzheimer's disease (AD) can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes these symptoms as indicative of which stage of the illness? 1. Stage 4: Mild-to-Moderate Cognitive Decline 2. Stage 5: Moderate Cognitive Decline 3. Stage 6: Moderate-to-Severe Cognitive Decline 4. Stage 7: Severe Cognitive Decline

4 Page: 252-253 Feedback 1 The client's symptoms do not indicate stage 4 of the illness. 2 The client's symptoms do not indicate stage 5 of the illness. 3 The client's symptoms do not indicate stage 6 of the illness. 4 The nurse should recognize that a client exhibiting these symptoms is in the severe cognitive decline, seventh stage, of AD.

9. A client diagnosed with AD has impairments of memory and judgment and is incapable of performing activities of daily living. Which nursing intervention should take priority? 1. Present evidence of objective reality to improve cognition. 2. Design a bulletin board to represent the current season. 3. Label the client's room with name and number. 4. Assist with bathing and toileting.

4 Page: 266 Feedback 1 Presenting evidence of objective reality to improve cognition is incorrect because it is not an activity of daily living. 2 Designing a bulletin board to represent the current season is incorrect because it is not an activity of daily living. 3 Labeling the client's room with name and number is not an activity of daily living. 4 The priority nursing intervention for this client is to assist with bathing and toileting. A client who is incapable of performing activities of daily living requires assistance in these areas to ensure health and safety.

2. A client diagnosed with vascular neurocognitive disorder (NCD) is discharged to home under the care of his wife. Which information should cause the nurse to question the client's safety? 1. His wife works from home in telecommunication. 2. The client has worked the nightshift his entire career. 3. His wife has minimal family support. 4. The client smokes one pack of cigarettes per day.

4 Page: 267 Feedback 1 Working from home does not suggest that the client could be injured. 2 Working the night shift does not suggest that the client could be injured. 3 Minimal family support does not suggest that the client could be injured. 4 The nurse should question the client's safety at home if the client smokes cigarettes. Patients with this disorder become confused and are at risk for injury.

12. An older client has recently moved to a nursing home. The client has trouble concentrating and socially isolates. A physician believes the client would benefit from medication therapy. Which medication should the nurse expect the physician to prescribe? 1. Haloperidol (Haldol) 2. Donepezil (Aricept) 3. Diazepam (Valium) 4. Sertraline (Zoloft)

4 Page: 272-273 Feedback 1 The client would most benefit from an antidepressant; haloperidol (Haldol) is not an antidepressant. 2 The client would most benefit from an antidepressant; donepezil (Aricept) is not an antidepressant. 3 The client would most benefit from an antidepressant; diazepam (Valium) is not an antidepressant. 4 The nurse should expect the physician to prescribe sertraline to improve the client's social functioning and concentration levels. Sertraline is a selective serotonin reuptake inhibitor antidepressant. Depression is the most common mental illness in older adults and is often misdiagnosed as a neurocognitive disorder.

6. Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during the substance induced disorder of alcohol withdrawal? 1. Antagonist therapy 2. Deterrent therapy 3. Codependency therapy 4. Substitution therapy

4 Page: 291 Feedback 1 Antagonist therapy does not accurately describe this CNS depressant medication. 2 Deterrent therapy does not accurately describe this CNS depressant medication. 3 Codependency therapy does not accurately describe this CNS depressant medication. 4 Various medications have been used to decrease the intensity of symptoms in an individual who is withdrawing from, or who is experiencing the effects of excessive use of, alcohol and other drugs. This is called substitution therapy and may be required to reduce the life-threatening effects of alcohol withdrawal.

4. Which client statement indicates a knowledge deficit related to a substance use disorder? 1. "Although it's legal, alcohol is one of the most widely abused drugs in our society." 2. "Tolerance to heroin develops quickly." 3. "Flashbacks from lysergic acid diethylamide (LSD) use may reoccur spontaneously." 4. "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."

4 Page: 307 Feedback 1 Cannabis is the second most widely abused drug in the United States. 2 This statement does not indicate a knowledge deficit. 3 This statement is true regarding LSD. 4 The nurse should determine that the client has a knowledge deficit related to substance use disorders when the client compares marijuana to smoking cigarettes and claims it to be harmless.

10. A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? 1. To assess for emotional strength 2. To assess for Wernicke-Korsakoff syndrome 3. To assess for tachycardia 4. To assess for fine tremors

4 Page: 315 Feedback 1 The nurse is not checking for emotional strength by holding the client's hand. 2 The nurse is not assessing for Wernicke-Korsakoff syndrome. 3 The nurse is not assessing for tachycardia. 4 The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, and coarse tremors.

9. Which client statement demonstrates positive progress toward recovery from a substance use disorder? 1. "I have completed detox and therefore am in control of my drug use." 2. "I will faithfully attend Narcotic Anonymous when I can't control my cravings." 3. "As a church deacon, my focus will now be on spiritual renewal." 4. "Taking those pills got out of control. It cost me my job, marriage, and children."

4 Page: 316-317 Feedback 1 This statement does not demonstrate positive progress in recovery. 2 Attending meetings infrequently puts the client at risk for relapse. 3 This statement does not indicate reflection and understanding on the impact of substance abuse. 4 A client who takes responsibility for the consequences of substance use disorder or substance addiction is making positive progress toward recovery. This would indicate completion of the first step of a 12-step program.

11. When under stress, a client routinely uses alcohol to excess. Finding her drunk, her husband yells at the client about her chronic alcohol abuse. Which action alerts the nurse to the client's use of the defense mechanism of denial? 1. The client hides liquor bottles in a closet. 2. The client yells at her son for slouching in his chair. 3. The client burns dinner on purpose. 4. The client says to the spouse, "I don't drink too much!"

4 Page: 7 Feedback 1 This behavior does not indicate denial. 2 Yelling at family members does not indicate denial. 3 Burning dinner on purpose is not an action that indicates denial. 4 The client's statement "I don't drink too much!" alerts the nurse to the use of the defense mechanism of denial. The client is refusing to acknowledge the existence of a real situation and the feelings associated with it.

1. A nurse is assessing a client who is experiencing occasional feelings of sadness because of the recent death of a beloved pet. The client's appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the client's behaviors? 1. The client's behaviors demonstrate mental illness in the form of depression. 2. The client's behaviors are extensive, which indicates the presence of mental illness. 3. The client's behaviors are not congruent with cultural norms. 4. The client's behaviors demonstrate no functional impairment, indicating no mental illness.

4 Page: 9 Feedback 1 The client's behaviors are to be expected in a time of grief. 2 The client's behaviors are not presented as being extensive. 3 The client's behaviors are to be expected after a loss. 4 The nurse should assess that the client's daily functioning is not impaired. The client who experiences feelings of sadness after the loss of a pet is responding within normal expectations.

2. During the planning of care for a suicidal client, which correctly written outcome should be a nurse's first priority? 1. The client will not physically harm self. 2. The client will express hope for the future by day three. 3. The client will establish a trusting relationship with the nurse. 4. The client will remain safe during the hospital stay.

4; Page: 236 Feedback 1 This answer choice is incorrectly written. Correctly written outcomes must be client focused, measurable, realistic, and contain a time frame. Without a time frame, an outcome cannot be correctly evaluated. 2 This option may take longer to achieve. 3 This option is important, but safety must be established first. 4 The nurse's priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurse's priority.

13. Which medication orders should a nurse anticipate for a client who has a history of benzodiazepine-withdrawal delirium? 1. Haloperidol (Haldol) and fluoxetine (Prozac) 2. Carbamazepine (Tegretol) and donepezil (Aricept) 3. Disulfiram (Antabuse) and lorazepan (Ativan) 4. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

4; Page: 291 Feedback 1 Haloperidol (Haldol) and fluoxetine (Prozac) would not effectively treat the client and are not appropriate. 2 Carbamazepine (Tegretol) and donepezil (Aricept) would not effectively treat the client and are not appropriate. 3 Disulfiram (Antabuse) and lorazepan (Ativan) would not effectively treat the client and are not appropriate. 4 The nurse should anticipate that a physician would order chlordiazepoxide and phenytoin for a client who has a history of benzodiazepine-withdrawal delirium. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy.