mental health uworld

a client with schizophrenia is started on clozapine. which periodic measurements take priority in this client?

CBC and absolute neutrophil count.

The nurse is speaking with the spouse of a client following a family discussion with the health care provider about the client's terminal condition and eligibility for hospice care. The spouse states, "I don't think I can make this decision right now. What would you do?" How should the nurse respond?

These decisions are challenging. Tell me your spouse's beliefs about end-of-life.

a client presents to the emergency department with alcohol intoxication. assessment shoes nystagmus, ataxia, and confusion. the client's breath smells of alcohol. which prescription from the health care provider should the nurse implement first?

Thiamine, IV

a client with schizophrenia is hospitalized. after 2 weeks of treatment, the frequency of the client's hallucinations seems to be diminishing. when first hospitalized, the client refused to leave the room. now the client spends time in the dayroom, sitting in a corner watching television, but does not initiate conversation or social interaction with other clients or staff. what is the most appropriate activity for the client?

a board game with a staff member

a nurse working at a mental health clinic is reviewing four messages from clients requesting a same-day appointment. which client does the nurse prioritize to call back first?

a client who is experiencing a fever and diarrhea 2 days after the health care provider increased the sertraline dose.

which clinical manifestations would the nurse identify with severe anorexia nervosa? SATA

amenorrhea fluid and electrolyte imbalances presence of lanugo weight loss of 25% below normal weight

the psychiatric nurse is developing a plan of care for a 16 yr old client with bulimia nervosa. which of the following interventions should the nurse include in the plan of care? SATA

ask if the client has experienced any thoughts of suicide. assess client frequently for signs of electrolyte imbalances. encourage the client to use a food diary for diet recall. establish ways for the client to be involved in the plan of care. monitor client for 1-2 hours after meals in a central area.

the school nurse is called to the classroom to assist with a 7 yr old with ADHD who is throwing books and hitting the other children. what is the best initial action for the nurse to take?

ask the child to blow up a balloon.

a 60 yr old client wanders away during halftime at a football game and is found 48 hrs later sleeping on a park bench, 100 miles from home. the client is brought to the emergency department by the police. the client can state the name and address but has no recollection of the past 2 days. what is the priority nursing action?

assess vital signs.

yesterday, the client was weaned from the mechanical ventilator and an intravenous infusion of lorazepam. the client has been alert and oriented for 24 hrs but is now experiencing confusion. the nurse now evaluates new-onset confusion by assessing the client's sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy. the nurse suspects which condition in this client?

delirium

the nurse is educating a client in preparation for discharge from the hospital when the client breaks down crying, saying that the health care provider thinks she is crazy because he diagnosed her with a functional disorder. which statement would be the best reply to this client?

functional disorder is a general diagnosis for a genuine medical issue that medical science does not yet fully understand.

a client with OCD has been cleaning a bathroom for most of the morning. when the roommate demands that the client leave the bathroom so that the roommate can shower, the client becomes angry and says, "you can't make me leave, everything is still dirty." what is the best nursing action?

give a reminder that the client has been cleaning the bathroom for 1 1/2 hours and it is time to take a break.

the nurse is planning care for an 11 yr old admitted for surgical treatment of a fractured femur. the child also has ADHD, predominantly inattentive type. what is the priority nursing action?

give the child a written schedule of daily activities.

a 10 yr old client with autism spectrum disorder is hospitalized for a diagnostic workup. which is the most appropriate nursing action?

giving the client a schedule of daily activities.

the emergency department nurse cares for a client with multiple bruises, a possible arm fracture, and a facial laceration. the client's spouse is at the bedside and appears angry. which action is the priority at this time?

have the spouse leave the room so that the client can be spoken with and examined in private.

the home health aide reports to the nurse care manager that the client has been trying to give away possessions. when the nurse asks the client about this behavior, the client says, "with my spouse dead, there's no reason for me to go on". what is the best priority response by the nurse?

have you had any thoughts of hurting yourself?

the mental health clinic nurse is evaluating the treatment plan for a client with OCD who counts backward from 5 to 1 many times a day. which of the following client statements indicates progress toward effective coping? SATA

having a heavier workload increases my anxiety and the urge to count, but i calm myself with deep-breathing exercises. i used to start counting as soon as i boarded the bus, but now i can ride for 30 minutes without counting. when i begin feeling anxious, i take a short, brisk walk so i can decompress and refocus.

a client on a medical unit recently received a diagnosis of end-stage renal disease and was told of the need to go on dialysis. this morning the client was found in the bathroom trying to commit suicide by hanging using hospital gowns the client was stabilized and transferred to the psychiatric unit. which of the following is the highest priority nursing action for this client?

provide continuous one-to-one observation with the client.

a client with schizophrenia has been hospitalized for a week and placed on an antipsychotic medication. the client tells the nurse of hearing multiple voices all day long arguing about whether the client is a good or bad person. the client says, "everyone tells me that the voices are not real, but they are driving me crazy". what is the best action by the nurse?

provide earphones and a dvd player and have the client sing along with the music.

the nurse is caring for a dying child on a palliative unit. which statement by the nurse is most important to make to the parents immediately following the death of their child?

some parents like to cuddle and speak to the child. take the time you need.

the nurse is caring for a client with a history of heroin abuse. which clinical finding may indicate withdrawal?

tachycardia

a client states, "i just don't know what to do about this situation with my parents," and the nurse replies, "i'm sure you will do the right thing." which summary is true regarding the nurse's response?

the response devaluates the client's feelings and gives false reassurance.

a client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. the spouse says to the nurse, "if i hadn't come home early from work, my spouse would be dead. i can't believe this is happening" what is the best response by the nurse?

this has been very overwhelming for you. what are you feeling right now?

the nurse speaks with a client diagnosed with schizophrenia who begins to look away toward the door and grimace. which statement by the nurse is most therapeutic at this time?

what do you see at the door?

which statement made by the nurse during a therapy session demonstrates a need for further instruction regarding effective therapeutic communication techniques?

why did you get so angry when she ignored you?

a female client who was the victim of acquaintance rape 2 months ago is receiving therapy for PTSD. she says to the nurse, "it's all my fault. i should have known not to accept a drink from someone i just met in a bar." what is the best response by the nurse?

you could not have anticipated the rape. you did not deserve or ask for it.

the health care provider has just informed a client who has diabetes and CKD of the need to start dialysis. the client tearfully says to the nurse, "i don't know what i'm going to do; everything was so overwhelming before, and now there is this." how should the nurse respond?

you sound very discouraged and frightened.

the nurse is caring for a client who entered the psychiatric ED in a state of acute psychosis after ingesting illicit substances. the parents ask the nurse if the client will develop schizophrenia. what is the most appropriate response by the nurse?

your son will have to remain here for observation until we know more.

a client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions. which nursing interventions should the nurse include in the client's plan of care with regard to the delusional thinking? SATA

focus on reality and verbally reinforce it. focus on the client's feelings secondary to the delusions.

which statement by the client with a diagnosis of dependent personality disorder would the nurse recognize as progress toward a positive therapeutic outcome?

my mother could not drive me here today, so i took the bus.

the new nurse is providing teaching to a client scheduled for ECT. what information given by the new nurse would cause the charge nurse to intervene?

"be sure to take your valproic acid prior to the procedure."

the nurse is caring for a new mother whose infant has been diagnosed with down syndrome. the client says to the nurse, "i'm so worried. my husband is so devastated that he won't even look at the baby." what is the best response by the nurse?

"how are you feeling about your baby?"

the nurse in a psychiatric clinic is evaluating the client's response to tx for somatic symptom disorder with cardiac manifestations. which client statement indicates a need for further treatment?

"i am looking for another heart specialist to evaluate my symptoms."

the clinic nurse speaks with the spouse of a client being treated for alcohol use disorder. which statements by the spouse indicate codependence? SATA

"i try to get up early and keep the children from being too loud in the mornings" "if i didn't get so stressed about my job, my spouse wouldn't drink so much" "when my spouse was sick, i called and rescheduled clients so my spouse could rest"

a client with a 20 yr hx of schizophrenia is hospitalized. the client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband. i can't find my headband. the oil is going to leak out of the crack in my head." what is the best response by the nurse?

"let's go back to your room and look for your headband together."

a 12 yr old with moderate intellectual disability and an IQ of 45 is hospitalized. what will the nurse recommend as the best recreational activity for this child?

connect-the-dots puzzle book.

a nurse is admitting a child and observes multiple irregular bruises. which action should the nurse take next?

continue with a detailed interview and physical examination.

the nurse cares for a client newly diagnosed with acute stress disorder following a traumatic event. which of the following communications by the nurse are appropriate? SATA

how has this situation affected your relationship with friends and family? it is normal to experience difficult symptoms after a traumatic event. please tell me about your current use of alcohol and any drugs. share with me any thoughts or plans of self-harm that you have had.

a nurse performs the initial assessments for 4 assigned clients. the nurse identifies which client as being at greatest risk for development of delirium?

80 yr old client with COPD, chronic respiratory failure, and urosepsis.

A client with moderate Alzheimer disease becomes agitated during mealtime and throws a plate of food on the floor. Which of the following responses by the nurse are appropriate? SATA

Distract and redirect the client by asking for help folding napkins for the following day's meals. Use direct eye contact and say to the client, "I can see that you are upset; this is a safe place."

The RN is leading a support group for partners of military veterans suffering from PTSD. A participant asks the nurse how to identify the typical symptoms of PTSD. The nurse responds that most individuals with PTSD report which symptoms?

Increased anxiety, reliving the event, feeling detached from others.

the student nurse is performing an assessment of a 10 yr old diagnosed with ADHD. in addition to the 3 core symptoms of ADHD (hyperactivity, impulsiveness, and inattention), which of the following would the student nurse expect to find during the assessment?

low self-esteem and impaired social skills.

the nurse is presenting an in-service educational session on child abuse and neglect to a class of certified home health abides. which of the following statements should the nurse include when discussing the characteristics of the typical perpetrator of child abuse? SATA

abusers often have a history of growing up in an environment of domestic violence. abusers often have a history of substance abuse. most child abusers have a sense of low self-esteem. teenage parents are particularly vulnerable to abusing their children.

a client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30 min commute via train. the nurse recognizes that this client most likely suffers from which psychological disorder?

agoraphobia

a nursing home client with major depressive disorder reports difficulty going to sleep until late at night. the client gets up, paces the hallway, wrings the hands, and appears teary. what interventions should be included in the client's nursing care plan? SATA.

allow the client to receive at least 20 minutes of natural sunlight each day. spend time with the client in a quiet environment just before bedtime. suggest that the client take a warm bath before going to bed.

the nurse is caring for a client newly admitted with an acute manic episode of bipolar disorder. the nurse identifies which dinner selection as the most appropriate to promote client nutrition?

cheeseburger, apple, vanilla milkshake.

the home health nurse visits a 75 yr old client with mild alzheimer dementia who recently moved in with a caregiver. which observations would cause the nurse to suspect neglect? SATA

client breaks eye contact when discussing caregiver. client has lost 8lb in the previous 4 weeks. client's eyeglasses have been visibly broken for 1 month. client's prescription medication is expired.

the nurse on the mental health unit received report on 4 clients. which client should the nurse see first?

client diagnosed with PTSD who reports an anxiety level of 8/10 and is pacing in the room.

the nurse is conducting a follow-up interview with a client who is being treated for depression and suicidal ideation. which factor best indicates the client is not currently at risk for suicide?

client has clear future plans involving personal goals and family milestones.

the nurse is reviewing the records of an adolescent client. which findings suggest that the client may need referral for depression screening?

client has had school disciplinary issues due to absenteeism and angry outbursts. client has lost approximately 8lb over the last 3 weeks without trying. client is often found sleeping during class or activities. client quit sports despite receiving previous athletic awards and trophies.

a client recently admitted to an inpatient unit for treatment of alcoholism says to the nurse, "I only came here to get away from my nagging spouse. sometimes i think my spouse is the one who should be here. i can stop drinking any time I want." the nurse recognizes that the client is exhibiting which of the following defense mechanisms?

denial and projection

a client has been admitted to the acute inpatient psychiatric unit with a diagnosis of major depressive disorder (unipolar depression). the nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which of the 2 key clinical findings daily for at least 2 weeks?

depressed mood or loss of interest/pleasure.

a client with GAD is referred to outpatient mental health department for CBT. the CBT includes which interventions and strategies?

desensitization to a specific stimulus or situation. relaxation techniques. self-observation and monitoring. teaching new coping skills and techniques to reframe thinking.

the mental health nurse is planning care for a client newly admitted with dissociative identity disorder. which interventions will the nurse include? SATA

develop a trusting relationship with each of the alternate identities. encourage the client to journal about feelings and dissociation triggers. listen for expressions of self-harm from the alternate identities. teach grounding techniques such as deep breathing to hinder dissociation.

the nurse is preparing discharge instructions for a client with a history of alcohol abuse on the third day after an emergency appendectomy. the nurse suspects delirium tremens based on which assessment data? SATA

diaphoresis hallucinations tachycardia

after a daily weigh-in, a client with anorexia nervosa realizes a 2 lb weight gain. the client says to the nurse in a distressed voice, "this is terrible. i'm so fat". what is the best response by the nurse?

i don't see you that way; you are making progress toward a healthy weight.

a client with alzheimer disease is admitted to the hospital for a urinary tract infection. the daughter says to the nurse, "i really want to take my mother home and continue care there. however, lately, my mother has become agitated and restless at night. i'm awake most of the night, feel exhausted, and do not know what to do." what is the best response by the nurse?

our social worker can discuss long-term care options with you.

the nurse makes a home visit to a client with alzheimer disease. while reviewing the client's home care needs, the client's spouse states, "it's hard to see my spouse worsen each day. i'm not sure i can keep doing this alone anymore." which response by the nurse is best?

tell me about the care you provide in a typical day and its challenges.

the clinic nurse reinforces education about intimate partner violence for a group of graduate nurses. which of the following are appropriate for the nurse to include?

the abusive partner often demonstrates jealousy and possessiveness. victims may not leave due to financial concerns or fear of harm by the abuser. violence against a female often intensifies during pregnancy.

the nurse cares for a client who just had surgical excision and biopsy of a tumor. the biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider. the client asks the nurse, "am i going to die?". which statement by the nurse is appropriate?

tell me more about your thoughts and feelings regarding the situation.

the registered nurse is counseling the parent of a child recently diagnosed with ADHD, combined type. which statement by the parent requires an intervention?

"my child will outgrow this disorder around age 20."

a young client is diagnosed with major depressive disorder. 3 weeks prior, the client's fiance broke off their engagement, claiming the client was "too fat and ugly". during a one-on-one interaction with the nurse, the client says, "my fiance is really wonderful and is not to blame for calling off the engagement. i look awful and i'm not much good for anything." what is the best response by the nurse?

"tell me how you felt when your fiance broke up with you."

a recently widowed client becomes tearful at a routine clinic visit and states, "I just can't get over my spouse's death". which of the following responses by the nurse are appropriate? SATA

"this is a difficult time. tell me about how you have been coping." "what are your thoughts about attending a grief support group?"

a client recently diagnosed with schizophrenia is hospitalized. the client appears distraught and says to the nurse, "the voices are bad today, they are so angry with me." which of the following is the best response by the nurse?

"what are the voices saying to you?"

the nurse assesses a pediatric client and finds bruises in various stages of healing on the back and legs. when questioned about the bruises the child begins to cry and states, "somebody did things to me." which of the following communications by the nurse is appropriate? SATA.

"what happened is not your fault. you are not to blame." "you did right by telling me. you are not in trouble."

a client recently diagnosed with schizophrenia is brought to the mental health clinic by the identical twin sibling for the first follow-up visit after hospitalization. the client's sibling says to the nurse, "i read that schizophrenia runs in families. i guess i'm doomed." which is the best response by the nurse?

"you are at risk for the disease. however, there are other factors that contribute to the development of schizophrenia."

a client on the locked unit of an inpatient psychiatric hospital says to a nurse on the evening shift, "during the day they let me out to go to the gift shop. you're my favorite nurse; i know you'll be a good sport and give me a pass" what is the best response by the nurse?

"you do not have privileges for leaving the unit. i cannot give you a pass"

the partner of a client with borderline personality disorder calls the clinic and reports coming home from work to find the client with self-inflicted superficial cuts to the arm. the partner tells the nurse, "my partner does something like this every time i have to go away on business. my partner is not serious about doing something really harmful, just trying to stop me from going away." what is the best response by the nurse?

"your partner needs to be seen in the clinic today."

a client with a hx of major depressive disorder with psychotic features was rescued before jumping off a dam. the client is pacing, picking at the arms, and repeatedly mumbling, "I have to die. you cannot stop me." when the health care provider recommends ECT as the initial tx, the client's spouse says to the nurse, "i can't allow such a cruel tx. why can't they just give my spouse meds?" which is the best response by the nurse?

"your spouse is very ill and ECT might be the best treatment at this time. what are your concerns about ECT?"

the nurse cares for a client who has a DNR prescription, and notes extensive skin mottling and vital sings consistent with impending death. the client's spouse states, "I hope my spouse can hang on a little longer; our anniversary is in 2 days." what response by the nurse is appropriate?

"your spouse's body is shutting down and the time is near; i will stay here with you."

a client with borderline personality disorder says to the nurse, "you're the only one i trust around here. the others don't know what they are doing and they don't care about anyone except themselves. i only want to talk to you." what is the priority action for the client's nursing care plan?

assign different staff members to care for the client each day.

which of the following actions would the nurse include in planning care for a client hospitalized for bipolar disorder, acute manic episode? SATA

assign the client to a private room. choose clothing for the client. have the client participate in physical exercise with a staff member.

the nurse is admitting a client with malnutrition r/t anorexia nervosa. which of the following actions are appropriate to include in the care of this client? SATA

assist the client in reflecting on triggers of disordered eating. maintain strict record of protein and calorie intake. remain with the client for the duration of each meal. weigh the client each morning prior to any oral intake.

the nurse plans care for a client newly admitted with OCD who is repeatedly counting magazines in the commons room. which of the following should the nurse include in the initial plan of care? SATA

assist the client to identify circumstances that increase anxiety. provide positive feedback when the client attends a group activity. refrain from judgmental comments about counting magazines. teach the client how to use the technique of thought stopping.

a client with moderate alzheimer disease is started on memantine. in evaluating the effectiveness of this medication, the registered nurse should assess the client for which of the following?

improved ability to perform activities of daily living.

the emergency department nurse cares for a client whose college roommate reports recent changes in the client's behavior. which behaviors and clinical data meet the criteria for involuntary admission to the mental health unit? SATA

client has refused food and water for 4 days and has poor skin turgor. client repeatedly mumbles, "I must kill them before they get me."

the nurse is caring for a hospitalized elderly client is is admitted with pneumonia. which assessment finding is most consistent with the diagnosis of delirium?

client is inattentive and hallucinating.

the clinic nurse reviews telephone messages left by 4 clients. which client is the priority to call back first?

client with schizophrenia hearing voices advising to harm a neighbor.

the nurse performs an initial assessment on a client with suspected PTSD. which assessments would support this diagnosis? SATA

difficulty concentrating feeling detached from others flashbacks of the traumatic event persistent angry, fearful

the nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family meeting and immediately begins to verbally abuse a roommate?

displacement

the nurse at a mental health clinic is performing a suicide risk screening on 4 clients experiencing depression. which client does the nurse recognize as being most at risk for suicide?

divorced male client with parkinson disease who was recently laid from his job.

the nurse in the outpatient treatment facility evaluates the plan of care for a client with with alcohol use disorder. which of the following client statements indicate positive progress toward recovery? SATA

drinking led to my divorce and the loss of my children. my focus is now on fitness training and going back to college. when cravings occur, i call my AA sponsor.

the nurse is caring for a client with bulimia nervosa. which is the most important time for the nurse the monitor the client's behavior?

during 1-2 hours after each meal.

the nurse is providing care to a client experiencing PTSD following a terrorist attack at the client's place of worship. what is the priority nursing action?

encourage the client to talk about the trauma.

a nurse is caring for a client who has tested positive for amphetamines and is experiencing paranoia. the client has a hx of physical violence. which intervention should the nurse implement at this time to prevent the client from becoming violent?

explain all activities of care clearly and calmly while facing the client.

the home health nurse assesses a child and suspects that the child is being abused. which of the following question are appropriate for the nurse to ask the caregiver? SATA

how would you describe your child's usual behavior at home? what forms of discipline do you use with your child when you are stressed, what coping mechanisms do you use who watches your child when you are at work

a new nurse is caring for an adolescent transgender client. what question would be appropriate when assessing the client's gender identity?

how would you describe your gender?

the triage nurse is assessing a client's risk for suicide after the client reports having thoughts of self-injury. which of the following statements by the client should the nurse recognize as risk factors for suicide? SATA

i am currently unemployed and looking for a job. i have multiple firearms at home stored in a safe. it has been a year since my last overdose. sometimes i experience feelings of hopeless.

an elderly client at the end of life is visited by family members. one begins to cry and asks the nurse, "will you please stay for a few minutes?". the nurse has other clients to care for as well. which statement by the nurse is the most helpful?

i can stay and sit with you if you would like.

the nurse is conducting a seminar for parents of adolescents about health issues common to this age group. which parent's statement indicates that the adolescent may have bulimia nervosa?

i found several empty boxes of laxatives in my child's wastebasket

a client with obesity reports several failed attempts at weight loss. which client statement best indicates that the client is ready and motivated for successful weight loss?

i have signed up to be a dog walker when i normally would watch television

the nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. the client says in a trembling voice, "there's a bad man standing over there in the corner of my room" what is the best response by the nurse?

i know you are frightened, but i do not see a man in your man in your room

the nurse is evaluating the plan of care for a client diagnosed with social anxiety disorder who has a fear of eating and drinking in public. which of the following client statements demonstrate an improvement in coping? SATA

i sat in the pizza shop and drank a cola while watching people eat and then bought a slice to go. i started having lunch with my coworkers even though i still become very anxious eating in public. i went to a coffee house with my boss and focused on an upcoming project while drinking a latte.

a client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of the bed except for toileting. the nurse enters the room to remind the client that breakfast will be served in the dining room in 20 min. the client says, "i'm not hungry and i don't feel like doing anything." what is the best response by the nurse?

i will help you get ready; then we can walk to the dining room together.

the nurse plans care for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. which client outcome will the nurse prioritize?

increases caloric intake to gain weight.

a client is receiving NGT feedings as nutritional rehabilitation for anorexia nervosa. after a weigh-in, the client learns of gaining 2lb (0.9kg) and says to the nurse, "see what your force feeding has done to me? i'm fatter and uglier than ever." what is the best action by the nurse?

initiate one-on-one supervision of the client during feedings.

a child with a high level of school absenteeism has been determined to have school phobia. the school nurse should counsel the child's parent/caregiver to take which action?

insist on school attendance immediately, starting with a few hours a day.

a client with a diagnosis of antisocial personality disorder was given a 2 hour pass to leave the hospital. the client returned to the unit 15 min past curfew and did not sign in. the next day, this behavior is brought up in a group meeting. the client says, "it's all the nurse's fault. the nurse was right there and did not remind me to sign in." what is the best response by the nurse?

it is your responsibility to sign in when you return from a pass.

an elderly client with dementia frequently exhibits sundowning behavior while living in a community-based residential facility. when the nurse finds the client wandering at night, which of the following statements is most appropriate?

it's time to get back to bed now.

the nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors?

likes to be center of attention, exaggerated emotional expression, little tolerance for frustration.

the nurse is caring for a client admitted with abdominal pain, who has been diagnosed with somatic symptom disorder after a through evaluation finds no medical cause for the symptoms. which intervention should the nurse include in the plan of care?

limit time spent discussing physical symptoms with the client.

the nurse provides teaching for a client newly prescribed disulfiram for alcohol abstinence. which information is the priority for the nurse to include?

list of everyday items containing hidden alcohol.

a client with schizophrenia says to the nurse, "the world turns as the world turns on a ball at the beach. but all the world's a stagecoach and i took the bus home." the nurse recognizes this statement as an example of which of the following?

loose associations

a nurse on the telemetry unit receives a client admitted from the emergency department with acute alcohol intoxication, confusion, and a diabetic toe ulcer. which intervention would be the priority?

monitor blood glucose levels during the night.

a client who is diagnosed with breast cancer asks the nurse, "am i going to die?" which statement by the nurse promotes a therapeutic relationship?

people with cancer experience fear of dying; tell me about your concerns.

after a client with alzheimer disease is found wandering in the middle of the street at 3am and returned by police, the community health nurse teaches family members about measures to keep the client safe at home. what is the most important strategy for the nurse to include in the instruction?

place a chain lock on the door above or below the client's eye level.

the spouse brings a client to the emergency department due to erratic behavior and expressions of despair. the emergency department is extremely busy with many clients. when the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. what initial action should the triage nurse take?

place the client in an inside hallway with one-on-one observation.

the nurse is managing the care of a client diagnosed with chronic anxiety. which behavior demonstrates to the nurse that the client possesses resilience?

practices stress reduction techniques daily.

an 87 yr old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation, confusion, and disorientation to time and place. what is the most important nursing action?

providing one-on-one supervision.

a client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. the client is now shaking, hyperventilating, and having heart palpitations. what is the priority nursing action?

remain in the room with the client

a newly admitted client with schizophrenia has been exhibiting severe social withdrawal, odd mannerisms, and regressive behavior. the client is sitting alone in the room when the nurse enters, says "good morning", and proceeds to sit down next to the client. without responding, the client stands up and starts to leave. which of the following actions is best for the nurse to take?

remain silent and allow the client to leave

a client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. which of the following is the priority nursing diagnosis?

risk for deficient fluid volume.

a young adult with obesity comes to the free clinic for a 2 week post antibiotic follow-up visit for a superficial abdominal skin abscess. the client has a history of major depressive disorder and was hospitalized twice in the past 6 months for attempted suicide. the client now reports feeling "emotionally upset, alone, and at the end of my rope," due to difficulty finding a job and inability to qualify for medical insurance. the client is currently prescribed fluoxetine but has not been able to follow up with the prescribing HCP. what is the priority nursing diagnosis at this time?

risk for suicide

an adolescent client is brought to the emergency department by the parents after being found making superficial cuts along the side of an arm with a razor blade. there are several minor cuts in various stages of healing on the client's forearms. which statements are appropriate for the nurse to make to the client's parents? SATA

tell me about when you started noticing this behavior. we have the bleeding under control. you must be very upset after seeing this.

the nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. which client statement supports this symptom?

that song is a message sent to me in secret code

the nurse is caring for a client with paranoid personality disorder. when the nurse directs the client to go to the dining room for dinner, the client says, "and eat that poisonous food? you better not make me go anywhere near that room" which statement best explains the client's behavior?

the client has an intense need to control the environment.

the client with narcissistic personality disorder often behaves in grandiose and entitled ways, believes that he/she is perfect, and relies on constant reinforcement and admiration from people perceived as ideal. what is the best explanation for these clinical characteristics?

the client is attempting to maintain self-esteem.

a client with social anxiety disorder is receiving treatment at the local community mental health center. which situation most likely caused the client to seek therapy?

the client's boss has asked the client to represent the company at an upcoming convention.

a client with a history of OCPD is seeking treatment for a gastrointestinal disorder and is scheduled for a colonoscopy at 10am. due to a computer glitch, the procedure is postponed to 3 pm. which response would be characteristic of an individual with OCPD?

this is unacceptable. i had my whole day planned out.

a nurse is caring for a client who was admitted following a suicide attempt. which client statement is most concerning?

very soon everything will be much better.