Mental Health

As the nurse arrives to visit a family 2 days after release from the hospital, she hears shouting and swearing between the mother and father and several loud crashes, just as she is going to knock on the door. What action by the nurse is the most appropriate? Return to the car and call the police. Return to the car and call the family on a cell phone. Knock on the door and wait to see if someone comes to the door. Knock on the door and shout, "It is the nurse. Can I help you?"

Return to the car and call the police.

A client who has just had electroconvulsive therapy (ECT) asks for a drink of water. Which intervention would be the nurse's priority? check the client's blood pressure assess the gag reflex obtain a body temperature determine level of consciousness

assess the gag reflex Explanation: The nurse must check the client's gag reflex before allowing the client to have a drink after an ECT procedure. Blood pressure and body temperature don't influence whether the client may have a drink after the procedure. The client would obviously be conscious if he's requesting a glass of water.

A client is in the manic phase of Bipolar I disorder. What therapeutic activity should the nurse promote for this client? playing a card game playing a vigorous basketball game playing a board game painting

painting Explanation: An activity that promotes minimal stimulation, such as painting, is the best choice. Activities such as cards, basketball, or a board game may escalate hyperactivity and should be avoided.

The nurse is caring for a client diagnosed with bulimia and observes the Russell sign. What symptoms will the nurse observe? pharyngitis ecchymosis around the face bruised knuckles tooth enamel erosion

bruised knuckles Explanation: Russell sign is bruised knuckles. Tooth enamel erosion and pharyngitis can also happen in the bulimic client. Ecchymosis around the face is not related to Russell sign.

What medication would probably be ordered for the acutely aggressive schizophrenic client? Lithium carbonate Haloperidol Amitriptyline Chlorpromazine

Haloperidol Explanation: Haloperidol administered I.M. or I.V. is the drug of choice for acute aggressive psychotic behavior. Chlorpromazine is also an antipsychotic drug; however, it causes more pronounced sedation than haloperidol. Lithium carbonate is useful in bipolar disorder, and amitriptyline is used for depression.

A nurse is caring for a 23-year-old client who was diagnosed with anorexia nervosa at the age of 14. The client continues to have fear related to eating. She admits that she has been using laxatives daily and occasionally will self-induce vomiting after eating. She is 5 feet 5 inches tall and weighs 100 pounds (45.5 kgs). The nurse expects to find which physical manifestations? Bradycardia and fever Tachycardia and fever Hypotension and hypothermia Hypertension and fever

Hypotension and hypothermia Explanation: Because of prolonged, inadequate nutritional intake, vomiting, and the use of laxatives, the nurse would expect to find low blood pressure (hypotension) and low temperature (hypothermia). Bradycardia, tachycardia, and hypertension aren't expected physical manifestations in this case.

The nurse is reinforcing discharge instructions for a female client that has a spinal cord injury at the C4 level. Which information should the nurse include with the instructions? "After a spinal cord injury, menstruation usually stops." "After a spinal cord injury, women are usually unable to conceive a child." "Sexual intercourse shouldn't be different for you." "After a spinal cord injury, women usually remain fertile; therefore, you may consider contraception if you don't want to become pregnant."

"After a spinal cord injury, women usually remain fertile; therefore, you may consider contraception if you don't want to become pregnant." Explanation: After a spinal cord injury, women remain fertile and can conceive and deliver a child. If a woman doesn't want to become pregnant, she must use contraception. Menstruation isn't affected by a spinal cord injury, but sexual functioning may be different.

While pacing in the hall, a client with schizophrenia runs to the nurse and says, "Why are you poisoning me? I know you work for central thought control! You can keep my thoughts. Give me back my soul!" How should the nurse respond during the early stage of the therapeutic process? "I'm a nurse. I'm not poisoning you. It's against the nursing code of ethics." "I'm a nurse, and you're a client in the hospital. I'm not going to harm you." "I'm not poisoning you. And how could I possibly steal your soul?" "I sense anger. Are you feeling angry today?"

"I'm a nurse, and you're a client in the hospital. I'm not going to harm you." Explanation: The nurse should directly orient a delusional client to reality, especially to place and person. Options 1 and 3 may encourage further delusions by denying poisoning and offering information related to the delusion. Validating the client's feelings, as in option 4, occurs during a later stage in the therapeutic process.

A client has been recently started on phenelzine, a monoamine oxidase (MAO) inhibitor. Which statements indicate that the client requires further educational reinforcement about this type of drug? Select all that apply. "If I have any insomnia I will drink warm milk." "I will avoid excessive amounts of chocolate and caffeine." "My family will just have to put up with any new irritability" "I will change positions slowly, as dizziness may occur." "I will have my neighbor check my blood pressure if I experience a headache."

"If I have any insomnia I will drink warm milk." "My family will just have to put up with any new irritability" Explanation: Clients are instructed to notify a healthcare provider right away if any insomnia worsens or new irritability occurs. Clients should be warned that the use foods like excessive chocolate and caffeine beverages, or medications may cause a reaction characterized by headache and other serious symptoms due to a rise in blood pressure. Clients taking phenelzine should be closely followed for symptoms of postural hypotension. Hypotensive side effects have occurred in hypertensive, as well as normotensive and hypotensive clients.

A client on an inpatient psychiatric unit has been taking a tricyclic antidepressant (TCA) without satisfactory results, so the health care provider changes the medication to a monoamine oxidase inhibitor (MAOI). Prior to administering the medication, what should the nurse be sure to check? The MAOI is initiated at the same dosage as the tricyclic antidepressant (TCA). Adequate time has elapsed between discontinuing the first medication and beginning the second. The client is not allergic to cheese. The client is free of suicidal thoughts and ideation.

Adequate time has elapsed between discontinuing the first medication and beginning the second. Explanation: Administering a TCA and MAOI within a short time frame to the client on an inpatient psychiatric unit increases the risk of hypertension and hyperpyrexia. Dosages of MAOIs and TCAs can vary widely. Whether the client is not suicidal or is not allergic to cheese is irrelevant to the choice of drug or timing of its administration. When using a MAOI, the client should avoid ingestion of aged cheese, which contains tyramine and could lead to a hypertensive crisis.

The nurse attempts to establish a therapeutic relationship with a client in the behavioral health unit. The nurse is reading the client's chart, becomes familiar with the medications the client is taking, and arranges for a meeting. What phase of the nurse-client relationship is the nurse demonstrating? confidentiality phase working phase orientation phase termination phase

orientation phase Explanation: Hildegard Peplau (1952) described three phases of the nurse-client relationship: The orientation phase begins when the nurse and client meet and ends when the client begins to identify problems to examine. During the orientation phase, the nurse establishes roles, the purpose of the meeting, and the parameters of subsequent meetings; identifies the problems, and clarifies expectations. The nurse gathers all relevant information before meeting with the client.

The nurse is having a conversation with a depressed client. The client states, "Do you think I should tell my family how I feel?" What is the most therapeutic response by the nurse? "I am not sure they would understand, but you could try." "Do you think you should tell your family?" "Of course you should. Honesty is the best policy." "I think you should sit them down and talk with them about this."

"Do you think you should tell your family?" Explanation: By responding with "Do you think you should tell your family?" the nurse is demonstrating the therapeutic communication technique of reflecting. This allows the client to initiate the action, and the nurse is not providing an answer to the conflict. The other responses give advice, which is a nontherapeutic communication technique.

Which statement made by the nurse would be useful when reinforcing education for the client and family about phobias and the need for a strong support system? "Use a family support system on a temporary basis." "The need to be assertive can be reinforced by the family." "The family must set limits on inappropriate behaviors." "The family plays a role in promoting client independence."

"The family plays a role in promoting client independence." Explanation: The family plays a vital role in supporting the client in treatment and preventing the client from using the phobia to obtain secondary gains. Family support must be ongoing, not temporary. The family can be more helpful by focusing on effective handling of anxiety, rather than focusing energy on developing assertiveness skills. People with phobias are already restrictive in their behavior; more restrictions aren't necessary.

A home health nurse is caring for a client diagnosed with a functional neurologic symptom disorder manifested by paralysis in the left arm. An organic cause for the deficit has been ruled out. Which nursing intervention is most appropriate for this client? Perform all physical tasks for the client to foster dependence. Allot an hour each day to discuss the paralysis and its cause. Identify primary or secondary gains that the physical symptom provides. Allow the client to withdraw from all physical activities.

Identify primary or secondary gains that the physical symptom provides. Explanation: Primary or secondary gains should be identified because they're etiologic factors that can be used in problem resolution. The nurse should encourage the client to be as independent as possible, and intervene only when the client requires assistance. The nurse should not focus on the disability. The nurse should encourage the client to perform physical activities to the greatest extent possible.

A 5-year-old child sustained third-degree burns to the right upper extremity after tipping over a frying pan. Which skin structures would the nurse include when explaining a third-degree burn to the child's parent? epidermis only epidermis and dermis all skin layers and nerve endings skin layers, nerve endings, muscles, tendons, and bone

all skin layers and nerve endings Explanation: A third-degree burn involves all of the skin layers and the nerve endings. First-degree burns involve only the epidermis. Second-degree burns affect the epidermis and dermis. Fourth-degree burns involve all skin layers, nerve endings, muscles, tendons, and bone.

Which nursing intervention would help a client diagnosed with Alzheimer's disease (AD) perform activities of daily living? urge the client to perform all basic care without help tell the client that morning care must be done by 9 a.m. give the client a written list of activities he's expected to do provide ample time for the client to complete basic tasks

provide ample time for the client to complete basic tasks Explanation: Clients with Alzheimer's disease respond to the affect of those around them. A gentle, calm approach is comforting and non-threatening, while a tense, hurried approach may agitate the client. The client has problems performing independently; expecting him to perform self-care independently may lead to frustration.

Which reason best accounts for the physical symptoms in a client with a somatic symptom disorder? to cope with delusional thinking to provide attention for the individual to prevent or relieve symptoms of anxiety to protect the client from family conflict

to prevent or relieve symptoms of anxiety Explanation: Anxiety and depression commonly occur in somatic symptom disorders. The client prevents or relieves symptoms of anxiety by focusing on physical symptoms. Somatic delusions occur in schizophrenia. The symptoms allow the client to avoid unpleasant activity, not to seek individual attention. Somatization in dysfunctional families shifts the open conflict to the client's illness, thus providing some stability for the family, not the client.

A nurse implements care for a client in a dissociative fugue. What does the nurse recognize may have preceded this diagnosis? Select all that apply. witnessing a murder history of childhood trauma recent history of rape a panic attack surviving a tornado

witnessing a murder recent history of rape surviving a tornado Explanation: Fugue states usually begin abruptly after a major stressor, such as being raped, witnessing a crime, or experiencing a natural disaster, and end abruptly. Fugue states do not usually coexist with a mental disorder such as anxiety or panic attacks. Clients in fugue states also do not typically have a history of childhood trauma.

A client, age 40, is admitted for a surgical biopsy of a suspicious lump in her left breast. When the nurse comes to take her to surgery, she is tearfully finishing a letter to her two children. She tells the nurse, "I want to leave this for my children in case anything goes wrong today." Which response by the nurse would be most therapeutic? "In case anything goes wrong? What are your thoughts and feelings right now?" "I can understand that you're nervous, but this is really a minor procedure. You'll be back in your room before you know it." "Try to take a few deep breaths and relax. I have some medication that will help." "I'm sure your children know how much you love them. You'll be able to talk to them on the phone in a few hours."

"In case anything goes wrong? What are your thoughts and feelings right now?" Explanation: By acknowledging how the client feels, this response encourages further expression of thoughts and feelings. Minimizing feelings or offering empty reassurances isn't therapeutic or helpful. Deep breathing and preoperative medication would be appropriate only after the client's fears have been expressed and dealt with.

A client is admitted to the behavioral health unit for treatment of pedophilia and tells the nurse that the client doesn't want to talk about sexual behaviors. Which response from the nurse is most appropriate? "OK, I'll just write 'no comment.'" "I know this must be difficult for you." "I need to ask you the questions on the database." "It's your right not to answer my questions."

"I know this must be difficult for you." Explanation: Telling the client that the client's condition must be difficult acknowledges the client's feelings and opens communication. Insisting that the form must be completed doesn't open up communication or acknowledge the client's feelings. Clients have rights, but data collection is necessary so that help with the problem can be offered. Writing "no comment" alone would be inappropriate and not therapeutic.

The nurse is gathering data from a client that arrives in the clinic with generalized anxiety disorder (GAD). What statement made by the client does the nurse determine correlates with this diagnosis? "Every time I hear a loud noise, it takes my mind back to being in the war a year ago." "I worry about things all of the time that I have no control over." "I couldn't breath and thought I was having a heart attack on the train." "It makes me uncomfortable to be around people at a party."

"I worry about things all of the time that I have no control over." Explanation: Generalized anxiety disorder is characterized by excessive anxiety or worry for several months and related to several anxiety related symptoms. Post Traumatic Stress Disorder (PTSD) is related to experiencing a traumatic event or series of events. The symptoms occur approximately 3 months or more after experiencing the trauma. They do not experience excessive worry daily. Panic disorder is experienced by the client unexpectedly and repeatedly. The client reports strong physical symptoms such as chest pain, shortness of breath, and palpitations. Client's with social anxiety disorder have a fear of performing in front of others or being in social situations. They do not have excessive worry or difficulty concentrating on a regular basis.

While reviewing a client record, the nurse sees that the client has a documented history of microphobia. What behavior does the nurse anticipate the client exhibiting? refusing to fly in an airplane avoiding riding in a car washing the hands repetitively covering the ears during a storm

washing the hands repetitively Explanation: A specific phobia is characterized by an excessive and persistent irrational fear of specific objects or situations that actually pose little threat or danger. The common categories of phobias include fear of animals, heights, water, storms, blood, needles, flying, and elevators or other enclosed spaces. A client with microphobia has a fear of germs, so repetitive washing of the hands is anticipated. Avoiphobia, the fear of flying, is likely manifested as the refusal to fly in an airplane. The client who has amaxophobia, a fear of riding in cars, is likely to exhibit avoidance of riding in a vehicle. Brontophobia, fear of thunder, is likely to be manifested as covering the ears during a storm.

During a mental status examination, a client may be asked to explain such proverbs as "Don't cry over spilled milk." What about the client's ability to think is being assessed by the health care practitioner? Client's ability to think concretely Client's ability to think rationally Client's ability to think abstractly Client's ability to think tangentially

Client's ability to think abstractly Explanation: Abstract thinking is the ability to conceptualize and interpret meaning. It's a higher level of intellectual functioning than concrete thinking, in which the client explains the proverb by its literal meaning. Rational thinking involves the ability to think logically, make judgments, and be goal-directed. Tangential thinking is scattered, not goal-directed, and hard to follow. Clients with such conditions as organic brain disease and schizophrenia typically can't conceptualize and comprehend abstract meaning. They interpret such statements as "Don't cry over spilled milk" in a literal sense such as "Even if you spill your milk, you shouldn't cry about it."

The nurse is caring for a client who is in the panic level of anxiety. Which action is the nurse's highest priority? Encourage the client to discuss feelings. Provide for the client's safety needs. Decrease environmental stimuli. Respect the client's personal space.

Provide for the client's safety needs. Explanation: A client in the panic level of anxiety doesn't comprehend and can't follow instructions or care for basic needs. The client is unable to express feelings due to the level of anxiety. Decreased environmental stimulus is needed, but only after the client's safety needs and other basic needs are met. The nurse must enter the client's personal space to provide personal care because a client in panic can't do so.

A client with bulimia nervosa asks a nurse, "How can I ask for help from my family?" Which response is most appropriate? "When you ask for help, make sure you really need it." "Have you ever asked your family for help in the past?" "Ask family members to spend time with you at mealtime." "Think about how you can handle this situation without help."

"Have you ever asked your family for help in the past?" Explanation: The nurse should determine whether the client has ever been successful in asking for help because previous experiences affect the client's ability to ask for help now. The client needs to be able to ask for help anytime without analyzing the level of need. Asking other people to be present at mealtime isn't the only way to ask for help. Developing a support system is imperative for this client, not trying to handle the situation independently.

The nurse is preparing to discharge a client with depression from inpatient care. The client tells the nurse, "You helped me more than anyone else in this place. I am hoping you will still be there to help me once I am discharged." How should the nurse respond? "I am glad you found our work together productive. I am confident you will continue to improve with the support of the outpatient program team." "I really like you too and am happy to hear you enjoyed our time together. However, I am not able to stay in contact with you after you are discharged." "We discussed the boundaries of the nurse-client relationship when you were admitted to the facility. Did you want to review these rules now?" "Have confidence in yourself! You have come a long way and did the work required to improve. I am sure you will continue to do well without me!"

"I am glad you found our work together productive. I am confident you will continue to improve with the support of the outpatient program team." Explanation: When in the termination phase of the nurse-client working relationship, the nurse focuses on reinforcing appropriate boundaries while remaining supportive and solution-focused. Emphasizing that the client will have continued support through the outpatient program focuses on who will now be working with the client while also acknowledging the work the nurse and client have done together in the past. Saying "I like you" implies a personal rather than professional relationship, and this response only focuses on the termination of this working relationship without reassurance about the continued support available to the client. Simply focusing on the "rules" and reminding the client these were covered in the past lacks empathy and is not supportive of the client. Telling the client to "have confidence" is dismissive of the client's request for ongoing support.

The nurse is reinforcing education provided for the client and spouse regarding electroconvulsive therapy (ECT). What statement made by the client would indicate that further education is required? "I will have no further episodes of depression after I have the procedure." "I may have some short-term memory loss briefly after the procedure." "The anesthesiologist will be there to assist with my breathing during the procedure." "I will still take my antidepressant medication after the procedure."

"I will have no further episodes of depression after I have the procedure." Explanation: The client should understand that although ECT is used for relapse prevention in depression, the treatments, such as one per month, are used to maintain mood improvement. The client may not see any long-term improvement after one treatment. The other options are correct statements by the client.

The nurse is reinforcing education provided for the client and spouse regarding electroconvulsive therapy (ECT). What statement made by the client would indicate that further education is required? "I will have no further episodes of depression after I have the procedure." "I may have some short-term memory loss briefly after the procedure." "The anesthesiologist will be there to assist with my breathing during the procedure." "I will still take my antidepressant medication after the procedure."

"I will have no further episodes of depression after I have the procedure." Explanation: The client should understand that although ECT is used for relapse prevention in depression, the treatments, such as one per month, are used to maintain mood improvement. The client may not see any long-term improvement after one treatment. The other options are correct statements by the client.

A nurse is caring for a female client who has been prescribed alprazolam for panic attacks. After reviewing information about the medication, the nurse determines that the client has understood the information based on which response? "I'll stop taking the drug immediately if I experience any adverse effects." "I'll go to my health care provider's office weekly to have blood work done to monitor drug levels." "I'll skip a dose if I'm not having any panic attacks." "I'll discuss my plans for pregnancy with my health care provider."

"I'll discuss my plans for pregnancy with my health care provider." Explanation: Alprazolam is contraindicated in pregnancy; therefore, the client should be instructed to discuss plans for pregnancy with her health care provider. A client should be advised not to stop taking the drug abruptly without consulting with her health care provider because withdrawal symptoms or seizures may occur. Weekly blood tests are not indicated with alprazolam. The client should be advised not to skip doses.

A 2-year-old child is admitted through the emergency department with a suspected diagnosis of Hirschsprung's disease (aganglionic megacolon). The parent asks about treatment of the disease. What would be an appropriate response from the nurse? "The child will have a permanent colostomy and can learn the required care with maturity." "Initially the child will have a temporary colostomy; later a second operation removes the abnormal part of bowel and reattaches the normal bowel down to the rectum." "The child will require many reconstructive colostomy surgeries over the child's lifetime." "The child will require chemotherapy and radiation therapy in addition to surgery to treat the disease."

"Initially the child will have a temporary colostomy; later a second operation removes the abnormal part of bowel and reattaches the normal bowel down to the rectum." Explanation: Repair of aganglionic megacolon in a child with a suspected diagnosis of Hirschsprung's disease requires dissection of the aganglionic segment and anastomosis with the unaffected intestine. It is usually done in a two-stage operation. The first surgery creates a colostomy to evacuate the bowel of stool and rest the distended portion of the bowel. The second surgery, done several months later, involves colostomy closure and a rectal "pull-through." The colostomy is not permanent. Only a two-stage operation is required. Chemotherapy and radiation therapy are not required for this condition; it is not cancer.

A client has been taking lithium carbonate for 6 months and recently developed symptoms of arthritis. The client asks the nurse for ibuprofen for pain. What is the best response by the nurse? "Ibuprofen will cause lithium level to drop very low and arthritis symptoms may return." "Let me assess your pain level, then I will administer your ibuprofen." "Aspirin would be best for you, because ibuprofen can elevate your lithium blood level." "You will have to stop taking the lithium if you take any pain medication."

"Let me assess your pain level, then I will administer your ibuprofen." Explanation: Ibuprofen is an NSAID, which will increase renal lithium carbonate reabsorption; aspirin is also a NSAID, and does not increase lithium carbonate levels. Stronger analgesics are not necessary for mild arthritis. Not all pain medications are contraindicated while on lithium. However, ibuprofen will not cause the lithium level to fall too low.

A client recovering from alcohol addiction asks a nurse how to talk to his or her children about the impact of addiction on them. Which response by the nurse is most appropriate? "Try to limit references to the addiction and focus on the present." "Talk about all the hardships you've had in working to remain sober." "Tell them you're sorry and emphasize that you're doing so much better now." "Talk to them by acknowledging the difficulties and pain your drinking caused."

"Talk to them by acknowledging the difficulties and pain your drinking caused." Explanation: Part of the healing process for the family is to acknowledge the pain, embarrassment, and overall difficulties the client's drinking problem caused family members. Limiting references to the addiction facilitates the client's ability to deny the problem. Talking about the hardships of remaining sober prevents the client from acknowledging the difficulties his or her children endured. Apologizing leads the client to believe only a simple apology is needed. The addiction must be addressed, and the children's pain acknowledged.

A client tells the nurse that people from Mars are going to invade the earth. Which response by the nurse would be therapeutic? "That must be frightening to you. Can you tell me how you feel about it?" "There are no people living on Mars." "What do you mean when you say they're going to invade the earth?" "I know you believe the earth is going to be invaded, but I don't believe that."

"That must be frightening to you. Can you tell me how you feel about it?" Explanation: This response addresses the client's underlying fears without feeding the delusion. Refuting the client's delusion, as in option 2, would increase anxiety and reinforce the delusion. Asking the client to elaborate on the delusion, as in option 3, would also reinforce it. Voicing disbelief about the delusion, as in option 4, wouldn't help the client deal with his underlying fears.

While looking out the window, a client with schizophrenia remarks, "That school across the street has creatures in it that are waiting for me." Which nursing action is the most appropriate for this client? Ask the client why the creatures are waiting for him. Acknowledge the client's fears and insecurities. Explain to the client that there are no creatures in the school. Ignore the remark and redirect the client to group activities.

Acknowledge the client's fears and insecurities. Explanation: Acknowledging the client's fears and insecurities helps to establish a trusting relationship and increase feelings of safety. Asking the client why the creatures are waiting only serves to reinforce the delusional thoughts. Challenging the client's delusion may lead to agitation. Ignoring the remark doesn't reassure the client. A delusional client is not able to participate in group activities.

A client on an inpatient psychiatric unit has been taking a tricyclic antidepressant (TCA) without satisfactory results, so the health care provider changes the medication to a monoamine oxidase inhibitor (MAOI). Prior to administering the medication, what should the nurse be sure to check? Adequate time has elapsed between discontinuing the first medication and beginning the second. The MAOI is initiated at the same dosage as the tricyclic antidepressant (TCA). The client is free of suicidal thoughts and ideation. The client is not allergic to cheese.

Adequate time has elapsed between discontinuing the first medication and beginning the second. Explanation: Administering a TCA and MAOI within a short time frame to the client on an inpatient psychiatric unit increases the risk of hypertension and hyperpyrexia. Dosages of MAOIs and TCAs can vary widely. Whether the client is not suicidal or is not allergic to cheese is irrelevant to the choice of drug or timing of its administration. When using a MAOI, the client should avoid ingestion of aged cheese, which contains tyramine and could lead to a hypertensive crisis.

A client tells the nurse she has never had an orgasm and her partner is upset that he can't meet her needs. Which nursing intervention is most appropriate? Tell the client that most women don't reach orgasm. Assess the couple's perception of the problem. Refer the client to a therapist because she has sexual aversion disorder. Ask the client if she desires intercourse.

Assess the couple's perception of the problem. Explanation: Assessing the couple's perception of the problem will define it and assist the couple and the nurse in understanding it. A nurse can't make a medical diagnosis such as sexual aversion disorder. Most women can be taught to reach orgasm if there's no underlying medical condition. When assessing the client, the nurse should be professional and matter-of-fact; she shouldn't make the client feel inadequate or defensive.

The nurse in a psychiatric inpatient unit is caring for a client with obsessive-compulsive disorder. As part of the client's treatment, the psychiatrist orders lorazepam, 1 mg by mouth three times per day. During lorazepam therapy, the nurse should instruct the client to follow which advice? Avoid caffeine Avoid aged cheeses Stay out of the sun Maintain an adequate salt intake

Avoid caffeine Explanation: Ingesting 500 mg or more of caffeine can significantly alter the anxiolytic effects of lorazepam. Other dietary restrictions are unnecessary. Staying out of the sun or using sunscreens is required when taking phenothiazines. An adequate salt intake is necessary for clients receiving lithium.

A client is diagnosed with functional neurologic symptom disorder with paralysis of the legs. What's the best nursing intervention for the nurse to use? Discuss with the client ways to live with the paralysis. Focus interactions on results of medical tests. Encourage the client to move the legs as much as possible. Avoid focusing on the client's physical limitations.

Avoid focusing on the client's physical limitations. Explanation: The paralysis is used as an unhealthy way of expressing unmet psychological needs. The nurse should avoid speaking about the paralysis to shift the client's attention to the mental aspect of the disorder. The other options focus too much on the paralysis, instead of recognizing the underlying psychological motivations.

During an initial assessment, a client reports the following behaviors: social inhibition, hypersensitivity to negative evaluation, fear of criticism, and social ineptitude. A review of the collected data leads the nurse to suspect which personality disorder? Narcissistic Antisocial Paranoid Avoidant

Avoidant Explanation: The behaviors are avoidant behaviors. The client typically avoids activities because he fears criticism, disapproval, and rejection. Antisocial behaviors are against society but are not inhibited. Paranoid behaviors are those in which a client is suspicious of the actions of others, and narcissistic behaviors are self-centered.

The nurse is preparing to provide discharge teaching to a client with a generalized anxiety disorder. The client is exhibiting signs of mild anxiety. Which action should the nurse take? Continue with the discharge instructions and check for the client's understanding. Postpone the discharge instructions until the client is free from signs of anxiety. Offer the client a dose of the prescribed as needed (PRN) antianxiety medication. Encourage the client to relax in a quiet environment and reassess in 10 minutes.

Continue with the discharge instructions and check for the client's understanding. Explanation: Mild anxiety can make the client more attentive to instruction. Therefore, the nurse should continue the teaching. Mild anxiety requires no intervention, so there is no need to tell the client to relax in a quiet environment. The client who is being discharged is expected to experience some mild apprehension and excitement that can manifest as mild anxiety and it is unrealistic that the client will have no signs of anxiety. Antianxiety medication should be reserved for moderate to severe anxiety that does not respond to nonpharmacological interventions.

A client doesn't make eye contact with the nurse during an interview. The nurse suspects that the client's behavior has a cultural basis. What should the nurse do first? Ask staff members of a similar culture about the client's behavior. Observe how the client and his family and friends interact with each other and with other staff members. Read several articles about the client's culture. Accept the client's behavior because it's probably culturally based.

Observe how the client and his family and friends interact with each other and with other staff members. Explanation: Assessing the client's interactions with others helps to determine whether the behavior is part of a usual pattern. It also may help the nurse understand the meaning of the behavior for this particular client. Reading about a different culture, consulting other staff members, and talking with the client are helpful after the nurse has observed the client's interaction with others. The nurse must be able to accept the client as an individual but need not accept unhealthy or inappropriate behaviors. The nurse should work with the client to better understand his cultural differences.

An 8-year-old girl and her 5-year-old sister tell the school nurse that their mother frequently yells and spits in their faces when she is mad at them. The nurse hesitates to intervene because she knows the family personally. Which action by the nurse is appropriate? Schedule a weekly meeting with the children to monitor their situation. Call the mother and request a conference. Report the information to child protective services. Notify the grandfather, a local physician, to solicit help for his grandchildren.

Report the information to child protective services. Explanation: State laws dictate that day care providers, teachers, nurses, social workers, physicians, clergy, and coaches report all cases of suspected child abuse. Scheduling a weekly meeting to monitor the children's situation and calling the mother to request a conference may place the children in danger and violate the law. Notifying the grandfather breeches client confidentiality and also violates the law.

A client is admitted to an inpatient psychiatric unit. After data collection and admission procedures are completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in a specific corner of the dayroom." The nurse is communicating these planned nursing interventions for which main rationale? To establish a trusting relationship To provide a structured environment for the client To instill hope in the client To provide time for completing nursing responsibilities

To establish a trusting relationship Explanation: Availability, reliability, and consistency are critical factors in establishing trust with a client. Being specific about the time and place of meetings helps establish trust, which is initially the main objective. Although important, structuring the environment and instilling hope aren't the primary tasks at this time. Arranging a regular meeting with the client allows the nurse to plan the workload but isn't the major reason for such scheduling.

A client diagnosed as having panic disorder is admitted to the inpatient psychiatric unit. Until admission, he or she had been a virtual prisoner in the house for 5 weeks because of agoraphobia, afraid to go outside even to buy food. The nurse, when planning care for this client, determines which action as this client's overall goal? To help the client perform self-care activities To help the client function effectively in his or her environment To help control the client's symptoms To help the client participate in group therapy

To help the client function effectively in his or her environment Explanation: A client with panic disorder typically confines movements to increasingly smaller areas to avoid confronting fears, which may dominate the client's life and limit everyday activities. The overall goal of care is to help the client function within the environment as effectively as possible. Panic disorder doesn't impair the ability to perform self-care activities. Controlling symptoms isn't the overall goal; furthermore, helping the client function effectively will help control symptoms. Although participation in group therapy may help the client control symptoms, encouraging such participation isn't the overall goal of nursing care.

The nurse on the acute inpatient psychiatric unit is determining which clients on the unit should be placed in the rooms closest to the nurse's station to facilitate frequent observation. In which order does the nurse prioritize the clients? Place the clients in order from the highest priority for being in a room close to the nursing station to the lowest priority. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1 a client with depression who has just been admitted due to a suicide attempt 2 a client with a delusional disorder who is disoriented to both place and time 3 a client with conduct and borderline personality disorders who acts out impulsively 4 a client with bipolar disorder who is experiencing an episode of hypomania 5 a client with an anxiety disorder who performs frequent compulsive rituals

a client with depression who has just been admitted due to a suicide attempt a client with a delusional disorder who is disoriented to both place and time a client with conduct and borderline personality disorders who acts out impulsively a client with bipolar disorder who is experiencing an episode of hypomania a client with an anxiety disorder who performs frequent compulsive rituals Explanation: The nurse prioritizes clients based on the need for close observation to reduce the risk for harm. Although policies related to the frequency of observation will vary between facilities, the client who has recently attempted suicide should ideally be observed constantly using one-to-one observation. If this is not possible, checks are recommended at least every 15 minutes, making this client the highest priority for being in a room close to the nurse's station. The client who is disoriented may require frequent redirection and should be closely observed to prevent injury to the client or others. Therefore, the client with delusional disorder is of the next highest priority. The nurse prioritizes the client with conduct and borderline personality disorders next. The tendency to act out impulsively and contrary to unit rules means this client may require a moderate amount of redirection. In hypomania, the client is not as impulsive as when fully manic. Therefore, the client with bipolar disorder who has hypomania is at a lower priority for observation but may require direction related to behavior that is disruptive to others due to elevated mood. The client who performs compulsive rituals does not pose a risk to self or others. These rituals are used to reduce the experience of anxiety and do not require the nurse's close observation, so this client is assessed to be the lowest priority.

An older adult client has begun anticonvulsant therapy for the treatment of seizures following a stroke. Which assessment finding is essential to report to the health care provider? altered level of consciousness that fluctuates daily blood pressure of 130/84 mm Hg sleeping frequently throughout the day hand tremors making manual dexterity difficult

altered level of consciousness that fluctuates daily Explanation: Anticonvulsant therapy is a cause of delirium and the primary and often the initial sign of delirium is an altered level of consciousness that is seldom stable and usually fluctuates throughout the day. A blood pressure of 130/84 mm Hg should be recorded as slightly elevated, but is not essential to report to the health care provider at this time. A series of blood pressure readings are more helpful. It is common for older adults to sleep throughout the day. Hand tremors should be monitored.

The nurse is providing care to a client with Alzheimer's disease (AD). Which nursing intervention takes priority? establish a routine that supports former habits maintain physical surroundings that are cheerful and pleasant maintain an exact routine from day to day control the environment by providing structure, boundaries, and safety

control the environment by providing structure, boundaries, and safety Explanation: By controlling the environment and providing structure and boundaries, the nurse is helping to keep the client safe and secure, which is a priority nursing measure. Establishing a routine that supports former habits, maintaining cheerful, pleasant surroundings and an exact routine foster a supportive environment; however, keeping the client safe and secure takes priority.

A 13-year-old has received third--degree burns over 20% of the body. When observing this client 72 hours after the burn, which finding should the nurse expect? increased urine output severe peripheral edema respiratory distress absent bowel sounds

increased urine output Explanation: During the resuscitative-emergent phase of a burn, fluids shift back into the interstitial space, resulting in the onset of diuresis. Edema resolves during the emergent phase, when fluid shifts back to the intravascular space. Respiratory rate increases during the first few hours as a result of edema. When edema resolves, respirations return to normal. Absent bowel sounds occur in the initial stage.

A nurse is assisting with the development of a care plan for a client recovering from cocaine use. Which intervention should be the nurse's priority for this client? providing meticulous skin care initiating suicide precautions establishing frequent orientation obtaining nutritional consultation

initiating suicide precautions Explanation: Clients recovering from cocaine use are prone to "post-cocaine depression" and are likely to become suicidal if they can't take the drug. Skin care and frequent orientation are routine nursing interventions but aren't the most immediate considerations for this client. Nutrition consultation isn't the most pressing intervention for this client.

The nurse is obtaining a health history from a client with depression and determines the client is taking St. John's wort (hypericum). Which information should the nurse include when discussing this medication with the client? nonstandard preparation, so the amount of hypericum may vary among manufacturers much more expensive cost of preparation than other commonly prescribed drugs blood testing required every week for dyscrasias purchase amounts limited to a 2-week supply

nonstandard preparation, so the amount of hypericum may vary among manufacturers Explanation: St. John's wort (hypericum), which is an over-the-counter medication for depression, may have a nonstandard preparation and the amount of hypericum may vary among manufacturers. Other disadvantages of St. John's wort include reduced effectiveness compared to prescription drug therapy or cognitive therapy. In addition, drug interactions can occur and may be significant.

A nurse is caring for a client with agoraphobia. Which signs and symptoms would the nurse anticipate? Select all that apply. hallucinations panic attacks inability to leave home eating disorders alcohol consumption Tobacco use.

panic attacks inability to leave home Explanation: Agoraphobia is characterized by extreme anxiety and a fear of being in open places. Panic attacks and an inability to leave home are symptoms associated with the disorder. No correlation exists between fear of open spaces and hallucinations, eating disorders, alcohol consumption, or tobacco use.

A client with depersonalization/derealization disorder spends much of the day in a dreamlike state, ignoring personal care needs. What situation is this behavior most likely related to? organic brain damage impaired memory lack of information perceptual impairment

perceptual impairment Explanation: Because of time spent in a dreamlike state, the client's perception is impaired. Thus, many clients with depersonalization/derealization disorder ignore self-care needs. There's no known organic brain damage with this disorder. Memory impairment is more of a problem with other dissociative disorders, such as dissociative identity disorder and dissociative amnesia. The dreamlike state does not indicate a lack of information.

A client tells a nurse, "I've been clean from drugs for the past 5 years, but my life really hasn't changed." Which concept should be explored with this client? further education conflict resolution career development personal development

personal development Explanation: True recovery involves changing the client's distorted thinking and working on personal and emotional development. Before the client pursues further education, conflict resolution skills, or career development, it's imperative to devote energy to emotional and personal development.

The grandparents of a client with anorexia nervosa want to support the client, but are not sure what they should do. Which intervention is best? Encourage positive expressions of affection. Encourage behaviors that promote socialization. Discuss how eating disorders create powerlessness. Discuss the meaning of hunger and body sensations.

Encourage positive expressions of affection. Explanation: Clients with eating disorders need emotional support and expressions of affection from family members. It wouldn't be appropriate for the grandparents to promote socialization. Clients with eating disorders feel powerless, but it's better to have the grandparents focus on something positive. Talking about hunger and other body sensations isn't a useful strategy.

Nursing care for a client with schizophrenia must be based on valid psychiatric and nursing theories. The nurse's interpersonal communication with the client and specific nursing interventions must be: clearly identified with boundaries and specifically defined roles. warm and nonthreatening. centered on clearly defined limits and expression of empathy. flexible enough for the nurse to adjust the plan of care as the situation warrants.

flexible enough for the nurse to adjust the plan of care as the situation warrants. Explanation: A flexible plan of care is needed for any client who behaves in a suspicious, withdrawn, or regressed manner, or who has a thought disorder. Because such a client communicates at different levels and is in control of himself or herself at various times, the nurse must be able to adjust nursing care as the situation warrants. The nurse's role should be clear; however, the boundaries or limits of this role should be flexible enough to meet client needs. Because a client with schizophrenia fears closeness and affection, a warm approach may be too threatening. Expressing empathy is important, but centering interventions on clearly defined limits is impossible because the client's situation may change without warning.

The nurse is reinforcing education for a client with generalized anxiety disorder (GAD). What statement made by the client indicates the education has been understood by the client? "I've stopped drinking so much diet cola." "I've reduced my intake of carbohydrates." "I now eat less at dinner and before bedtime." "I've cut back on my use of dairy products."

"I've stopped drinking so much diet cola." Explanation: Clients with GAD can decrease anxiety by eliminating caffeine from their diets. It is not necessary for clients with generalized anxiety to decrease their carbohydrate intake, eat less at dinner or before bedtime (unless there are other compelling health reasons), or cut back on their use of dairy products.

Which outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder? Accept responsibility for own behaviors. Be able to verbalize own needs and assert rights. Set firm and consistent limits with the client. Allow the child to establish his own limits and boundaries.

Accept responsibility for own behaviors. Explanation: Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child. Options 3 and 4 aren't outcome criteria but interventions. Option 2 is incorrect because the oppositional child usually focuses on his own needs.

The nurse documents, "The client described her husband's abuse in an emotionless tone and with a flat facial expression." When reviewing the documentation, the nurse recognizes this statement is describing which aspect of the client's disposition? Mood Feelings Blocking Affect

Affect Explanation: Affect refers to a person's emotional expression (in this case, the manner in which the client talks about her experiences). Feelings are emotional states or perceptions. Blocking is the interruption of thoughts. Moods are prolonged emotional states expressed by the affect.

Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 38.7° C (101.6° F); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. After review of the data, the nurse suspects what is occurring with this client? A postoperative infection Alcohol withdrawal Acute sepsis Pneumonia

Alcohol withdrawal Explanation: The client's vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome. Although infection, acute sepsis, and pneumonia may arise as postoperative complications, they wouldn't cause this client's signs and symptoms and typically would occur later in the postoperative course.

A client with schizophrenia reports that hallucinations have decreased in frequency. Which intervention would be appropriate to begin addressing the client's problem with social isolation? Suggest that the client stay away from group activities. Name the client the leader of the client support group. Suggest that the client play solitaire. Ask the client to participate in a group sing-along.

Ask the client to participate in a group sing-along. Explanation: Encouraging the client to avoid activities is not conducive to socialization. Games can become competitive and can lead to anxiety or hostility. The client probably lacks sufficient social skills to lead a group at this time. Playing solitaire doesn't encourage socialization.

A client is struggling with alcohol dependence. Which communication strategy is most effective for the nurse? Speak briefly and directly. Avoid blaming or lecturing the client. Confront feelings and examples of perfectionism. Determine if nonverbal communication will be more effective.

Avoid blaming or lecturing the client. Explanation: Blaming or preaching to the client should be avoided, because the negativity created prevents the client from hearing what the nurse has to say. Speaking briefly to the client may not allow time for adequate communication. Perfectionism doesn't tend to be an issue. Determining if nonverbal communication will be more effective is better suited to a client with a cognitive impairment.

On admission to the mental health unit, a client tells the nurse she's afraid to leave the house for fear of criticism. She informs the nurse, "My nose is so big. I know everyone is looking at me and making fun of me. I had plastic surgery and it still looks awful!" These symptoms are an indication of which disorder? Paranoid personality disorder Body dysmorphic disorder Schizophrenia Antisocial disorder

Body dysmorphic disorder Explanation: This disorder is characterized by a belief that the body is deformed or defective in a specific way. Although elements of paranoia are evident, the focus on a defective body part is the clue. There is some evidence of a thought disorder; however, schizophrenia isn't likely. Antisocial personality is characterized by manipulative behavior.

A nurse is caring for a newly admitted client diagnosed with schizophrenia and is started on antipsychotic medication. When reviewing the client's file, which notation would alert the nurse to notify the health care provider before implementing? Client is scheduled to have a myelogram within 48 hours of admission. Client is using a barrier contraceptive. Client is 30 years of age. Client is Caucasian.

Client is scheduled to have a myelogram within 48 hours of admission. Explanation: The dye used in myelography may cause severe neuron reaction if given within 48 hours of starting a new antipsychotic medication. Client should use a barrier contraceptive because of serious potential congenital abnormalities. Antipsychotic medications are used with caution in the young and elderly clients. Certain cultural groups, such as Arab Americans, respond differently to antipsychotics. However Caucasians respond as expected.

The nurse collecting data on a client asks the client the meaning of the proverb "People in glass houses shouldn't throw stones." What is the nurse assessing by asking this question? Comprehension Concept formation General knowledge Orientation

Concept formation Explanation: The nurse is testing concept formation when she asks a client to interpret a common proverb. Asking the client to state his name and the time, date, place, and circumstance assesses the client's orientation. Comprehension can be assessed by asking the client to read a portion of a news article and explain it. To assess a client's general knowledge, the nurse can ask the client a question such as "Who is the vice president(vice prime minister)?"

A client diagnosed with alcoholism is exhibiting loss of control and physical dependence. The nurse suspects the client is in which phase of alcoholism? Prealcoholic phase Early alcoholic phase Crucial phase Chronic phase

Crucial phase Explanation: The crucial phase is marked by physical dependence. The Pre-alcoholic phase is characterized by drinking to medicate feelings and to relieve stress. The early phase is characterized by sneaking drinks, blackouts, rapidly gulping drinks, and preoccupation with alcohol. The chronic phase is characterized by emotional and physical deterioration.

A client with long-term body-focused repetitive behaviors including trichotillomania (hair pulling) finds support through an online website. The client begins to attend local meetings and realizes that a nurse from the clinic also attends. When approached outside of these meetings, how should the nurse respond? Pretend not to know the client. Let the client establish the rules. Discuss this to define the relationship. Stop attending this support group.

Discuss this to define the relationship. Explanation: Social media and self-help groups can contribute to blurred boundaries between personal and professional relationships. The nurse should take the lead to discuss boundaries with the client. This means that the relationship needs to be defined. Generally letting the client do this fails as the client does not understand the conflict and responds positively to having contact with the nurse outside of the professional setting. Pretending not to know the client can be hurtful, while leaving the group can be detrimental to the nurse.

A nurse is caring for a client with anorexia nervosa who requires a high-protein, high-calorie diet. When offering appropriate choices for snacks, which snack would be best for this client? chicken soup and crackers a doughnut and orange juice egg salad and peanuts cashews and strawberries

Egg salad and nuts (such as peanuts and cashews) would be best for the client with anorexia nervosa because they are high in protein and calories. Chicken soup, crackers, and strawberries are low-protein, low-calorie foods. Doughnuts and orange juice are low in protein.

After placing a client in full leather restraints, how often should the nurse check the client's circulation? Once per hour Once per shift Every 15 minutes Every 2 hours

Every 15 minutes Explanation: Circulatory as well as skin and nerve damage can occur quickly. Therefore, circulation should be assessed at least every 15 minutes. Checking every hour, 2 hours, or 8 hours is not often enough and could result in permanent damage to the client's extremities.

While shopping at a mall, a woman experiences an episode of extreme terror accompanied by anxiety, tachycardia, trembling, and fear of going crazy. A friend drives her to the emergency department, where a physician rules out physiological causes and refers her to the psychiatric resident on call. The nurse caring for this client would expect the health care practitioner to prescribe which medication to control the client's anxiety? Haloperidol Lorazepam Bupropion Paroxetine

Lorazepam Explanation: Lorazepam is a schedule IV drug used to treat anxiety. Reducing the client's anxiety will help her cope with stress. Haloperidol is an antipsychotic agent. Bupropion is an antidepressant. Paroxetine is a selective serotonin reuptake inhibitor used to treat depression. Remediation:

The nurse understands which psychological or personality factor is likely to predispose an individual to medication abuse? Low self-esteem and unresolved rage Desire to inflict pain upon one's self Dependent personality disorder Antisocial personality disorder

Low self-esteem and unresolved rage Explanation: Low self-esteem and repressed rage as well as depression can predispose an individual to search for solace in addictive medications. Usually, medications are used to minimize or blot out pain, rather than inflict additional pain. Personality disorders don't predispose a client to medication abuse; however, personality disorders, especially the antisocial ones, may be intensified by abuse.

A nurse is assisting with the plan of care for a neonate scheduled for diaphragmatic hernia repair. Which nursing action would help decrease gastric and bowel distention? Feed the infant. Provide tactile stimulation. Prevent the infant from crying. Place the infant supine.

Prevent the infant from crying. Explanation: The stomach and intestine in the chest cavity become distended with swallowed air from crying. Negative pressure from crying pulls the intestines into the chest cavity, increasing the amount of distention. The infant usually is not fed until after surgery. Tactile stimulation is limited because it may disturb the infant's fragile condition. The infant is always placed on the affected side.

When presenting a lecture on anxiety, which term would a nursing instructor use that refers to the primary unconscious defense mechanism which keeps intense anxiety-producing situations out of a person's conscious awareness? Repression Denial Regression Introjection

Repression Explanation: Repression, the unconscious exclusion of painful or conflicting thoughts, impulses, or memories from awareness, is the primary ego defense. Other defense mechanisms tend to reinforce anxiety. Introjection is an intense identification in which one incorporates another person's or group's values or qualities into one's own ego structure. Regression is a retreat to an earlier level of developmental behavioral during a time of stress. Denial is the avoidance of unpleasant realities by ignoring them.

Which communication strategy is best to use with a client with anorexia nervosa, who is having problems with peer relationships? Use concrete language and maintain a focus on reality. Direct the client to talk about what's causing the anxiety. Teach the client to communicate feelings and express self appropriately. Confront the client about being depressed and self-absorbed.

Teach the client to communicate feelings and express self appropriately. Explanation: Clients with anorexia nervosa commonly communicate on a superficial level and avoid expressing feelings. Identifying feelings and learning to express them are initial steps in decreasing isolation. Clients with anorexia nervosa are usually able to discuss abstract and concrete issues. Confrontation or directing the client to talk about what's causing the anxiety usually isn't effective communication strategy, because it may cause the client to withdraw and become more depressed.

A psychiatric treatment team is planning care for a client who was involuntarily admitted for treatment of depression and suicide ideation. When planning the client's care, what legal parameters of care should the nurse be aware of? The client is able to obtain release against medical advice. The client is in need of a public guardian. The client is considered to be incompetent. The client is able to refuse medications.

The client is able to refuse medications. Explanation: Competent clients have the right to refuse medications. Even though the client is an involuntary admission, the client is competent and able to be involved in treatment planning. Because the client was admitted involuntarily, the client is not able to obtain release. The client who is legally declared incompetent is given a court-appointed guardian or representative who is responsible for giving consent. A client is considered to be competent unless the court has declared that the client is incompetent. The client who is incompetent is not able to give or refuse consent for treatment.

The nurse is preparing to administer chlorpromazine to a client with schizophrenia. Which circumstance, noted in the client's history, would cause the nurse to notify the health care provider for accuracy of the prescription? The client is also receiving labetalol. The client is diagnosed with intractable hiccups. The client had surgery and is restless. The client has a history of nausea and vomiting.

The client is also receiving labetalol. Explanation: The combination of antipsychotics with beta blockers may lead to an increase in the effect of both medications; therefore, caution should be taken before combining these drugs. Chlorpromazine is used in the treatment of intractable hiccups, postoperative restlessness, and nausea and vomiting.

Mental health laws in each state specify when restraints can be used and which type of restraints are allowed. Most laws stipulate which information regarding the use of restraints? Use for a maximum of 2 hours Use as necessary to control the client Use if the client poses a present danger to himself or others Use only with the client's consent

Use if the client poses a present danger to himself or others Explanation: Most states allow restraints to be used if the client presents a danger to himself or others. This danger must be reevaluated every 4 hours for an adult, every 2 hours for children ages 9 to 17, and hourly for children younger than age 9. If the client is still a danger, restraints can be used until the violent behavior abates. No standing orders for restraints are allowed, and restraints are permitted only until less restrictive measures become effective. Obtaining consent isn't necessary.

A client is taking a central nervous system stimulant. What should the nurse be sure to closely monitor this client for? Select all that apply. increased appetite, slowing of sensorium, and arrhythmias hyperpyrexia, slow pulse, and weight gain restlessness, palpitations, and insomnia tachycardia, weight loss, and mood swings hypotension, weight gain, and listlessness

tachycardia, weight loss, and mood swings restlessness, palpitations, and insomnia Explanation: Stimulants produce mood swings, anorexia, restlessness, palpitations, insomnia, weight loss, and tachycardia. The other symptoms indicate CNS depression.

The nurse is providing group therapy for a group of adolescents who witnessed the violent death of a peer. Which outcome would best meet the needs of the students? to learn violence prevention strategies to talk about appropriate expression of anger to discuss the effect of the trauma on their lives to develop trusting relationships among their peers

to discuss the effect of the trauma on their lives Explanation: By discussing the effect of the trauma on their lives, the adolescents can grieve and develop effective coping strategies. Learning violence prevention strategies isn't the most immediate concern after a trauma occurs, nor is working on developing healthy relationships. It's appropriate to talk about expressing anger after the trauma is addressed.

The health care provider prescribes a new drug for a client with generalized anxiety disorder. Which teaching will the nurse provide? "Taking this medication is the best way to control anxiety." "Repeat for me how to take this medication as prescribed." "This medication has helped many people so it should help you also." "If this medication doesn't help, you can stop taking it anytime."

"Repeat for me how to take this medication as prescribed." Explanation: A key nursing role is teaching. When a client has been prescribed a new drug, the nurse's role is to teach the client how to take the medication, provide information about side effects, and assess the client's learning. This is accomplished by having the client repeat back how to take the medication as prescribed. Telling the client that the medication is the best way to control anxiety is incorrect, as lifestyle modifications can be made also. Stating that the medication has helped others does not teach or assess the client's ability to learn. Anxiolytic drugs should not be stopped suddenly; instead, the nurse will teach that the client must contact the health care provider before discontinuing the medication.

A nurse knows that gender is part of one's identity. Which event signifies when gender is first ascribed? A child receives sex-specific toys. A child attends school. A neonate is born. A child receives sex-specific clothing.

A neonate is born. Explanation: As soon as a neonate is born, gender is ascribed. In the hospital, a neonate is given either a pink or blue name band, card, or blanket. Sexual identity is reaffirmed throughout the school years. Gender identification is perpetuated throughout life with sex-specific clothing and toys.

Which foods are contraindicated for a client taking tranylcypromine? Whole-grain cereals and bagels Chicken livers, Chianti wine, and beer Oranges and vodka Chicken, rice, and apples

Chicken livers, Chianti wine, and beer Explanation: A client taking a monoamine oxidase inhibitor antidepressant, such as tranylcypromine, shouldn't eat foods containing tyramine. Such foods include chicken livers, Chianti wine, beer, ale, aged game meats, broad beans, aged cheeses, sour cream, avocados, yogurt, pickled herring, yeast extract, chocolate, excessive caffeine, vanilla, and soy sauce. The client also must refrain from taking cold and hay fever preparations that contain vasoconstrictive agents.

When planning care for a client who has ingested phencyclidine (PCP), which of the following is the highest priority? Client's physical needs Client's safety needs Client's psychosocial needs Client's medical needs

Client's safety needs Explanation: The highest priority for the nurse working with a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily. After safety needs have been met, the client's physical, psychosocial, and medical needs can be met.

A client is taking a central nervous system stimulant. What should the nurse be sure to closely monitor this client for? Select all that apply. hyperpyrexia, slow pulse, and weight gain tachycardia, weight loss, and mood swings hypotension, weight gain, and listlessness increased appetite, slowing of sensorium, and arrhythmias restlessness, palpitations, and insomnia

Correct response: tachycardia, weight loss, and mood swings restlessness, palpitations, and insomnia Explanation: Stimulants produce mood swings, anorexia, restlessness, palpitations, insomnia, weight loss, and tachycardia. The other symptoms indicate CNS depression.

A client with long-term body-focused repetitive behaviors including trichotillomania (hair pulling) finds support through an online website. The client begins to attend local meetings and realizes that a nurse from the clinic also attends. When approached outside of these meetings, how should the nurse respond? Pretend not to know the client. Stop attending this support group. Let the client establish the rules. Discuss this to define the relationship.

Discuss this to define the relationship. Explanation: Social media and self-help groups can contribute to blurred boundaries between personal and professional relationships. The nurse should take the lead to discuss boundaries with the client. This means that the relationship needs to be defined. Generally letting the client do this fails as the client does not understand the conflict and responds positively to having contact with the nurse outside of the professional setting. Pretending not to know the client can be hurtful, while leaving the group can be detrimental to the nurse.

Nurses are aware that older clients' physiological changes of aging can complicate drug therapy. Which statement that describes how elderly clients react to medications must nurses be cognizant of? Elderly clients metabolize medications quickly when they age. Elderly clients are at risk for increased adverse effects to medications. Due to aging, elderly clients need higher dosages to respond to the same medication. Elderly clients tolerate medication better because they are less active as they age.

Elderly clients are at risk for increased adverse effects to medications. Explanation: As individuals become older, their livers metabolize drugs at a slower rate. Cumulative effects can occur and increase the risk of adverse effects. Elderly clients typically need lower dosages not higher. Level of activity typically doesn't affect a person's reaction to medication.

An elderly client admitted to the psychiatric unit for periods of confusion and outbursts of anger, shouts, "Get out of my house! Don't come any closer!" when a nurse enters his room. Which intervention by the nurse is best in this situation? Place the client in a room close to the nurses' station. Tell family and friends to restrict their visits. Encourage the family to remain with the client until bedtime. Keep the room well lit around the clock.

Encourage the family to remain with the client until bedtime. Explanation: Encouraging the family to remain with the client until bedtime promotes reality orientation. Restricting visitors may cause further disorientation. It may also be necessary to move the client to a room that is close to the nurses' station, to maintain client safety when the family leaves. However, doing so doesn't take priority over requesting that the family stay with the client. The lights in the room should be turned off at night to encourage a normal sleep pattern.

A client experiencing alcohol withdrawal reports itching everywhere from the bugs on the bed. Which action by the nurse is appropriate? Examine the client's skin. Ask what kind of bugs they are. Tell the client there are no bugs on the bed. Tell the client he is having tactile hallucinations.

Examine the client's skin. Explanation: Make sure the client doesn't have a rash, skin allergy, or something on the skin (such as food crumbs) causing discomfort. Reality should then be presented to the client gently without being derogatory. The nurse shouldn't support the client's hallucinations.

Nursing care for a client after electroconvulsive therapy (ECT) should include: bed rest for the first 8 hours after a treatment. nothing by mouth for 24 hours after the treatment because of the anesthetic agent. assessment of short-term memory loss. no special care.

assessment of short-term memory loss. Explanation: The nurse must assess the client's level of short-term memory loss after ECT. The client might need to be reoriented. The client can get out of bed and eat as soon as he or she feels comfortable.

A nurse notices that a client admitted for treatment of major depression is pacing, agitated, and becoming verbally aggressive toward other clients. What is the immediate care priority? ensuring the safety of this client and other clients on the unit offering the client a less-stimulating area in which to calm down removing the other clients from the area until this client settles down isolating the agitated client and offering sedation to calm the behavior

ensuring the safety of this client and other clients on the unit Explanation: Ensuring the safety of this client and other clients on the unit is the nurse's immediate priority. Moving the agitated client to a less-stimulating environment, isolating the client, or sedating the client address the client's needs but don't address those of the other clients. Removing other clients from the area until the agitated client calms down addresses the safety of the other clients without addressing the needs of the agitated client.

When collecting data from a 6-year-old child who has a 20% deep partial-thickness (second-degree) burn of the arms and trunk, the nurse determines that the child has damage to what layer(s) of skin? epidermis epidermis and part of the dermis epidermis and all of the dermis dermis and subcutaneous tissue

epidermis and part of the dermis Explanation: A deep partial-thickness burn affects the epidermis and part of the dermis. A superficial partial-thickness (first-degree) burn affects the epidermis only. A full-thickness (third-degree) burn involves epidermis and all of the dermis, as well as nerves and blood vessels in the skin.

A nurse on the psychiatric unit is caring for a client with antisocial personality disorder. Which behavior is the nurse most likely to observe? manipulation, shallowness, and the need for immediate gratification tendency to profit from mistakes or learn from past experiences expression of guilt and anxiety regarding behavior acceptance of authority and discipline

manipulation, shallowness, and the need for immediate gratification Explanation: Because of the lack of scruples and underlying powerlessness of the client with antisocial personality disorder, the nurse expects to see manipulation, shallowness, impulsivity, and self-centered behavior. This client doesn't profit from mistakes and learn from past experiences, lacks anxiety and guilt, and is unable to accept authority and discipline.

A nurse is monitoring a client for signs of early alcohol withdrawal. Which most consistent assessment finding associated with early alcohol withdrawal would the nurse expect to find? Heart rate of 120 to 140 beats/minute Heart rate of 50 to 60 beats/minute Blood pressure of 100/70 mm Hg Blood pressure of 140/80 mm Hg

Heart rate of 120 to 140 beats/minute Explanation: Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Mild hypertension typically occurs in early withdrawal; hypertension with diastolic pressure greater than 100 is associated with later symptoms. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs carefully throughout the entire alcohol withdrawal process.

How can the nurse help a client with anorexia nervosa recognize distortions of thought? Identify the client's misperceptions of self. Acknowledge immature and childlike behaviors. Determine the consequences of a faulty support system. Explain why healthy eating is important.

Identify the client's misperceptions of self. Explanation: Questioning the client's misperceptions and distortions will create doubt about how the client views themself. Acknowledging immature behaviors or determining the consequences of a faulty support system won't promote recognition of self-distortions. Explaining why healthy eating is important will not help the client recognize distortional thought.

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? pH Bicarbonate (HCO3-) Partial pressure of arterial oxygen (PaO2) Partial pressure of arterial carbon dioxide (PaCO2)

Partial pressure of arterial oxygen (PaO2) Explanation: The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation.

The nurse is working in a psychiatric facility on an anxiety disorder unit. The unit is locked and clients have scheduled group and family therapy sessions. Which other standard is maintained on this unit for a client diagnosed with panic disorder? Clients may come and go as they desire. Clients may eat anything that is facility prepared. Suicide precautions are instituted. A security guard is present at the door.

Suicide precautions are instituted. Explanation: Clients with anxiety disorders including panic disorder are at risk for suicide because they can be impulsive. Unit standards include maintaining suicide precautions. Nutritional problems do not typically accompany panic disorder and family can bring in client requests. Clients, depending on their status, typically remain on the unit; however, while there is facility security, there is no guard at the unit door.

Teaching for women in their childbearing years who are receiving antipsychotic medications should include which of the following facts? Increased libido is an adverse effect of these medications. Incidence of dysmenorrhea increases. The client should continue using contraception during periods of amenorrhea. Amenorrhea is irreversible.

The client should continue using contraception during periods of amenorrhea. Explanation: Women may experience amenorrhea, which is reversible, while taking antipsychotics. Amenorrhea doesn't indicate cessation of ovulation; therefore, the client can still become pregnant. The client should be instructed to continue contraceptive use even when experiencing amenorrhea. Dysmenorrhea isn't an adverse effect of antipsychotics, and libido generally decreases because of the depressant effect.

A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome? The student discusses conflicts over drug use. The student accepts a referral to a substance abuse counselor. The student agrees to inform the parents of the problem. The student reports increased comfort with making choices.

The student accepts a referral to a substance abuse counselor. Explanation: All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor.

A nurse is collecting data from a client who has a history of substance abuse. The client reports nausea, vomiting, and diarrhea and the nurse observes flushing, piloerection, increased lacrimation, and rhinorrhea. The nurse suspects that the client is most likely experiencing withdrawal from which substance? alcohol cocaine opioids amphetamines

opioids Explanation: Typical symptoms of opioid withdrawal, which can occur in clients who abuse opioids such as heroin and hydrocodone, include flushing, piloerection, nausea, vomiting, abdominal cramps, increased lacrimation, and rhinorrhea. Alcohol withdrawal symptoms include tachycardia, disorientation, confusion, agitation, and inability to sleep, and, if severe, delirium tremens and seizures. Cocaine withdrawal symptoms include depression with possible suicidal ideation, sleep disturbances, poor concentration, and cravings for cocaine. Amphetamine withdrawal symptoms are similar to those of cocaine but are not as pronounced.