Mental Health - UWorld

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? 1. "I found several empty boxes of laxatives in my child's wastebasket." 2. "I have noticed my child has started wearing bulky, oversized clothing." 3. "My child has lost 20 lb (9.1 kg) in the past 2 months." 4. "My child has stopped going to the gym."

1 Bulimia nervosa (BN) is an eating disorder characterized by episodes of uncontrollable binge-eating (consuming very large amounts of food, often in secret) followed by inappropriate compensatory behaviors to prevent weight gain. Compensatory behaviors may include laxative or diuretic use, self-induced vomiting, or excessive exercise 1-2 hours after binging (Option 1). Other signs of BN may include: - Physical changes related to self-induced vomiting (eg, scars or calluses on the hand, enlarged parotid glands, erosion of tooth enamel, dental caries) - Preoccupation with body image, weight, food, and dieting (Options 2 and 3) Losing a significant amount of weight and hiding the weight loss (eg, wearing oversized, bulky clothing) are characteristics of clients with anorexia nervosa. (Option 4) A client with BN would likely increase the amount of time spent exercising, not stop exercising. Educational objective: Bulimia nervosa is an eating disorder characterized by episodes of binge-eating followed by actions to prevent weight gain (eg, laxative overuse, self-induced vomiting, excessive exercise). Psychosocial Integrity

A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this client most likely suffers from which psychological disorder? 1. Agoraphobia 2. Generalized anxiety disorder 3. Social anxiety disorder 4. Zoophobia

1 Individuals with agoraphobia have fear and anxiety about being in (or anticipating) certain situations or physical spaces. The fear they experience is out of proportion to any actual danger. These individuals are also highly concerned about having trouble escaping or getting help in the event of a panic attack or panic symptoms. The primary psychological need in agoraphobia is to avoid panic, and individuals with this condition will engage in various behaviors to lessen anxiety and avoid specific situations. In severe agoraphobia, the individual may become homebound, not going to public places for fear of experiencing a panic attack that may cause them to become embarrassed or perform an uncontrollable act. The person with agoraphobia will often feel the need to be accompanied by a relative or friend when facing situations. Agoraphobic individuals most typically fear being in the following situations: - Outside the home alone - In a crowd or standing in line - Traveling in a bus, train, car, ship, or airplane - On a bridge or in a tunnel - Open spaces (eg, parking lots, marketplaces) - Enclosed spaces (eg, theaters, concert halls, stores) (Option 2) In generalized anxiety disorder, the anxiety is evident in various situations and can impact all areas of an individual's life (eg, workplace, family/relationships, general well-being). (Option 3) In social anxiety disorder, individuals fear being scrutinized, observed, or embarrassed in social or performance settings (eg, public speaking, eating in public). (Option 4) Zoophobia is fear of animals. Educational objective: Agoraphobia is characterized by intense anxiety about being in a situation from which there may be difficulty escaping in the event of a panic attack. A person with agoraphobia may avoid open spaces, closed spaces, riding in public or private

The nurse in a psychiatric clinic is evaluating the client's response to treatment for somatic symptom disorder with cardiac manifestations. Which client statement indicates a need for further treatment? 1. "I am looking for another heart specialist to evaluate my symptoms." 2. "I asked my spouse for support while I deal with my mother's death." 3. "I have started carrying a sketchbook to draw in when I am stressed." 4. "I journal daily about my stress level and any heart-related symptoms."

1 Somatic symptom disorder (SSD) is a psychological disorder in response to stress that results in symptoms of physical disorders (eg, chest pain, syncope) for which there is no identifiable medical source (eg, myocardial infarction, hypotension). Periods of increased stress (eg, work demands, family events) frequently precede the onset, or worsening, of physical symptoms and result in frequent requests for medical attention and treatment. SSD and care-seeking behaviors may then be reinforced and perpetuated by secondary gains (eg, social affirmation, "sick role," avoidance of unpleasant activities). When evaluating clients' responses to treatment for SSD, the nurse should monitor for the following indicators of positive progress: - Identification of alternate support systems for stress (eg, spouse, friends) (Option 2) - Identification of perceived benefits (ie, secondary gains) of behaviors - Use of stress-reducing strategies (eg, drawing, meditating) rather than fixation on symptoms (Option 3) - Verbalization of factors causing or worsening symptoms (Option 4) (Option 1) When medical treatment does not support a diagnosis for the physical symptoms, the client may become frustrated and seek the opinion of additional health care providers. This indicates a lack of treatment progress. Educational objective: Somatic symptom disorder (SSD) occurs when psychological stresses manifest as physical symptoms of illness without physiological cause. Treatment has been effective if the client with SSD is able to identify alternate support systems for stress, identify perceived benefits of behaviors, employ stress management strategies, and verbalize factors associated with symptoms. Psychosocial Integrity

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? 1. "I have signed up to be a dog walker when I normally would watch television." 2. "I understand that losing weight would improve my health and well-being." 3. "I want to lose 8 pounds (3.6 kg) so that my formal gown will fit in 4 weeks." 4. "My spouse and children are always encouraging me to eat healthier."

1 Successful behavior modification (eg, diet and exercise for effective weight loss) requires client readiness and motivation to change, which can be assessed using the Stages of Change Model. With the appropriate support (eg, listening, not pressuring the client), clients can move from one stage to the next: Precontemplation: The client does not believe a problem exists, although others may point it out (eg, encouraging healthy eating) (Option 4). Contemplation: The client recognizes a change is needed but is undecided whether it would be possible or worthwhile (Option 2). Preparation: The client has decided to change, explores emotions related to the decision, and begins establishing goals (eg, fitting into a dress) (Option 3). Action: The client has firmly committed to changing, has developed a plan (eg, dietary modifications, exercise plans), and actively takes steps toward new behavior (eg, choosing activity over television) (Option 1). Maintenance: The client continues to uphold the new behavior and focuses on preventing relapse. Termination: The client has achieved the desired change. This stage may be theoretical, as relapse to former behaviors is always possible. Educational objective: Successful behavior modification requires client readiness and motivation to change, as evidenced by the client developing and acting on a plan. Clients often do not initially see the need for change, but with the appropriate support they begin contemplating change, preparing to change (eg, goal setting), and then actively changing. Psychosocial Integrity

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? 1. Give the client a book to read 2. Provide earphones and a DVD player and have the client sing along with the music 3. Tell the client that the voices will go away when the medication starts to work 4. Tell the client to ignore the voices

2 Auditory hallucinations are the most common type of hallucination and are typically experienced by individuals with a diagnosis of schizophrenia, bipolar disorder, or other psychotic illness. Antipsychotic medication therapy is the first-line treatment of hallucinations and other psychotic symptoms. However, most psychotropic drugs may take some time to be completely effective and may not eliminate hallucinatory episodes entirely. Clients should be encouraged to develop alternate methods for coping with the hallucinations. One approach is increasing the amount of external auditory stimulation in the environment. Individuals with auditory hallucinations have reported that increasing the amount of external sound (eg, watching TV or listening to music through headphones) makes it easier to ignore internal sounds from the hallucinations. Other methods of managing auditory hallucinations include voice dismissal (telling the voices to go away) and cognitive behavioral therapy (assists clients in learning new ways to think about and deal with their symptoms). (Option 1) Reading a book may provide some distraction, but it does not increase external auditory stimulation. (Option 3) The medication may not start to work for another 2 weeks and may not eliminate these symptoms entirely. (Option 4) The client is hearing voices all day long; ignoring them is not as effective as an activity that distracts the client from the hallucinations. Educational objective: Although antipsychotic medication is the first-line treatment for diminishing or eliminating psychotic symptoms, such as hallucinations, clients need other strategies for coping with distressing symptoms. Increasing external auditory stimulation often helps distract the client from the internal voices and focus on reality. Psychosocial Integrity

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? 1. Baked sweet potato, kale, yeast roll, water 2. Cheeseburger, apple, vanilla milkshake 3. Spaghetti with meatballs, fruit salad, milk 4. Vegetable soup, salad, dinner roll, iced tea

2 Bipolar disorder is a psychiatric condition characterized by cycling periods of depression and mania. Clients with acute mania often display elevated mood, increased and excessive activity levels, and altered decision-making that can result in high-risk behavior (eg, hypersexuality, excessive spending). Clients with mania are also easily distractible, leading to neglect of personal needs (eg, hydration, nutrition, sleep, hygiene) and the need for medical intervention. When managing the nutritional needs of clients with mania, the nurse should frequently offer energy- and protein-dense foods that are easily carried and consumed (eg, sandwiches, shakes, hamburgers, pizza slices, burritos, fruit juices, granola bars). These "on-the-go" foods promote nutritional intake in clients who are unable to sit down and complete a traditional meal (Option 2). (Option 1) Sweet potatoes and kale are low in energy and protein and difficult to eat on the go. (Option 3) Spaghetti with meatballs and fruit salad are difficult to eat on the go. (Option 4) Vegetable soups and salads are often low in protein and energy and difficult to eat on the go. Caffeinated drinks (eg, soda, tea, coffee) should be avoided as they may increase mania and activity. Educational objective: Clients with acute mania often have elevated activity levels that increase their risk for malnutrition and dehydration. Nurses should provide easily carried and consumed foods high in energy and protein (eg, burgers, sandwiches, shakes) to promote adequate nutritional intake. Basic Care and Comfort

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? 1. Concrete thinking 2. Loose associations 3. Tangentiality 4. Word salad

2 Disturbance in logical form of thought is characteristic and one of the positive symptoms of schizophrenia. The client will often have trouble concentrating and maintaining a train of thought. Thought disturbances are often accompanied by a high level of functional impairment, and the client may also be agitated and behave aggressively. Types of impaired thought processes seen in individuals with schizophrenia include the following: Neologisms - made-up words or phrases usually of a bizarre nature; the words have meaning to the client only. Example: "I would like to have a phjinox." Concrete thinking - literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase, "The grass is always greener on the other side," would be interpreted to mean that the grass somewhere else is literally greener (Option 1). Loose associations - rapid shifting from one idea to another, with little or no connection to logic or rationality (Option 2) Echolalia - repetition of words, usually uttered by someone else Tangentiality - going from one topic to the next without getting to the point of the original idea or topic (Option 3) Word salad - a mix of words and/or phrases having no meaning except to the client. Example: "Here what comes table, sky, apple." (Option 4) Clang associations - rhyming words in a meaningless, illogical manner. Example: "The pike likes to hike and Mike fed the bike near the tyke." Perseveration - repeating the same words or phrases in response to different questions Educational objective: Disturbance in thought process (form of thought) is one of the positive symptoms of schizophrenia. The nurse needs to be able to recognize and identify the various types of thought disturbances experienced by clients with schizophrenia. These include loose associations, neologi

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? 1. "Do you have any friends in the building?" 2. "Have you had any thoughts of hurting yourself?" 3. "Tell me more about how you're feeling." 4. "You're not thinking of killing yourself, are you?"

2 Giving away possessions and making statements such as, "There is no reason for me to go on," are indications of suicidal ideation. The most important nursing action is to perform a suicide risk assessment to determine interventions to ensure the client's safety. Determining if the client has had thoughts of self harm is a priority. The nurse can ask the client direct questions such as, "Do you feel like hurting yourself?" or "Are you thinking about killing yourself?" or "Do you want to die?" During the assessment, it is important for the nurse to create a sense of trust and compassion and engage the client in a nonjudgmental manner. Additional questions that are part of a suicide risk assessment include the following: 1. Have you thought about how you would kill yourself? 2. Do you have a plan to kill yourself? 3. If you were to kill yourself, how would you do it? If the client has a suicide plan, the nurse needs to ask about the details. The risk of a client completing suicide increases when the client has planned for a specific time and place, has chosen a highly lethal method (eg, firearm, hanging), and has chosen circumstances in which there would be little or no chance of interruption. (Option 1) It is important to assess the client's social support system, but it is not the priority assessment. (Option 3) This is not the priority assessment; it is more important to determine if the client is thinking about suicide or has a plan. (Option 4) This is a leading question and implies what the answer should be. Educational objective: A suicide risk assessment is the priority nursing action for a client who expresses thoughts about "not wanting to go on" or "wishing for death" or engages in potential suicidal indicators such as giving away possessions. Asking the client directly about thoughts of hurting or kil

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? 1. The client has a problem with authority figures 2. The client has an intense need to control the environment 3. The client is hearing voices 4. The client is trying to control anger

2 Individuals with paranoid personality disorder have a pervasive distrust and suspicion of others; they believe that people's motives are malicious and assume that others are out to exploit, harm, or deceive them. These thoughts permeate every aspect of their lives and interfere with their relationships. Individuals with paranoid personality disorder are usually difficult to get along with as they may express their suspicion and hostility by arguing, complaining, making sarcastic comments, or being stubborn. Because these clients do not trust others, they have a strong need to be self-sufficient and maintain a high degree of control over their environment. (Option 1) This statement best describes an individual with antisocial personality disorder. (Option 3) Clients with paranoid personality disorder do not have psychotic symptoms. (Option 4) Clients with paranoid personality disorder will usually not be able to control their anger when confronted with a real or imagined threat. Educational objective: Paranoid personality disorder is characterized by distrust and suspicion of others. Because these clients do not trust other people, they have an intense need to control them and their environment. Psychosocial Integrity

The registered nurse is leading a support group for partners of military veterans suffering from posttraumatic stress disorder (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? 1. Auditory hallucinations, feelings of paranoia, isolation from others 2. Increased anxiety, reliving the event, feeling detached from others 3. Rapidly changing emotions, delusions, lethargy 4. Recurring nightmares, uncontrollable anger, daytime sleepiness

2 Posttraumatic stress disorder (PTSD) is a reaction to a traumatic or catastrophic event that is typically life-threatening to oneself or others. There are 3 categories of PTSD symptoms: 1. Reexperiencing the traumatic event Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or strong physical reactions to event reminders (rapid, pounding heart; gastrointestinal distress; diaphoresis) 2. Avoiding reminders of the trauma Examples include avoidance of activities, places, thoughts, or other triggers that could be trauma reminders, feeling detached and emotionally numb, loss of interest in life, lack of future goals, and amnesia related to important details of the event 3. Increased anxiety and emotional arousal Examples include insomnia, irritability, outbursts of anger and/or rage, difficulty concentrating, hypervigilance, and feeling jumpy (Option 1) Auditory hallucinations and feelings of paranoia are not characteristic symptoms of PTSD. These are characteristic of schizophrenia. (Option 3) Rapidly changing emotions, delusions, and lethargy are not characteristic symptoms of PTSD. (Option 4) Daytime sleepiness is not characteristic of PTSD. Educational objective: The 3 categories of PTSD symptoms include reexperiencing the traumatic event, avoiding reminders of the trauma, and increased anxiety and emotional arousal. Psychosocial Integrity

The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors? 1. Fears abandonment, agreeable, needs constant reassurance 2. Likes to be the center of attention, exaggerated emotional expression, little tolerance for frustration 3. Seems uncomfortable around people, lack of close friends, indifferent to praise or criticism 4. Tries to intimidate others, manipulative, lacks empathy

2 The nurse should recognize the following characteristics associated with histrionic personality disorder: - Self-dramatizing, exaggerated or shallow emotional expression - Attention-seeking, needs to be the center of attention - Overly friendly and seductive, attempts to keep others engaged - Demands immediate gratification and has little tolerance for frustration An individual with histrionic personality disorder displays these behaviors and characteristics persistently. The signs and symptoms are maladaptive and have a negative impact on the client's social, interpersonal, and occupational life. (Option 1) Clients with dependent personality disorder fear separation and tend to be indecisive and unable to take the initiative. They are often preoccupied with the thought of being left to fend for themselves and want others to assume responsibility for all major decision making. (Option 3) Clients with schizoid personality disorder exhibit social detachment and an inability to express emotion. They do not enjoy close relationships and prefer to be aloof and isolated. (Option 4) Clients with antisocial personality disorder have a pattern of disregard for and violation of the rights of others. They manipulate others for personal gain and lack empathy. Educational objective: Histrionic personality disorder is characterized by persistent attention-seeking behavior and exaggerated emotionality. The client with this disorder demands immediate gratification and has little tolerance for frustration. Psychosocial Integrity

A nurse is caring for a client who has tested positive for amphetamines and is experiencing paranoia. The client has a history of physical violence. Which intervention should the nurse implement at this time to prevent the client from becoming violent? 1. Administer prescribed PRN lorazepam and apply soft wrist restraints 2. Explain all activities of care clearly and calmly while facing the client 3. Place the client in the room that is closest to the nurses' station 4. Request security personnel to be present to protect clients and staff

2 Violence in the health care setting poses a safety risk to clients, staff, and visitors. It also decreases the quality of care that a violent client receives due to avoidant and fearful behaviors by staff. Risk factors for violence include altered level of consciousness, substance abuse, emotional stress, and behavioral/psychiatric disorders. Nursing interventions that help prevent violence include using clear, thorough communication (Option 2); encouraging active participation in care; promoting a low-stimulation environment; and providing comfort through pharmacological and nonpharmacological methods. The nurse should demonstrate undivided attention to the client (eg, facing the client, unhurried body language, calm tone). (Option 1) Chemical (eg, lorazepam) and physical restraints should be used only as last resorts to keep clients and others safe. It is not appropriate to use restraints to prevent escalation to violence. (Option 3) Placing the client near the nurses' station may increase anxiety due to the noise and activity in that area. The client should be closely monitored, but this is not an effective intervention for preventing violence. (Option 4) The presence of security personnel does not prevent violence and may cause increased client anxiety. The nurse should consider other interventions (eg, effective communication) to prevent violence. Educational objective: Violence is a safety concern for all in the health care setting. Nurses must identify those at risk for violent behavior and use clear, thorough communication to prevent violence. The nurse should provide undivided attention to the client while explaining all activities of care in a calm tone. Psychosocial Integrity

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? Select all that apply. 1. Client has been sleeping on the floor in the den rather than the bed 2. Client has refused food and water for 4 days and has poor skin turgor 3. Client repeatedly mumbles, "I must kill them before they get me" 4. Marijuana was found in the client's personal belongings 5. The health care provider makes a diagnosis of schizophrenia

2, 3 Clients have the right to refuse hospital admission and treatment. However, all states and provinces have laws and procedures for involuntary admission that require clients to receive inpatient treatment for a psychiatric disorder against their will. The legal criteria for involuntary admission include: - The individual appears to be an imminent danger to self or others (Option 3). - The individual has a grave disability (ie, is unable to adequately care for basic needs [food, clothing, shelter, medical care, personal safety]) as a result of a mental illness (Option 2). Clients also have the right to the least restrictive environment in which treatment can be provided in a safe manner. Involuntary commitment is generally used as a last resort in dealing with a client whose illness is so severe that judgment and insight in deciding to refuse treatment are markedly impaired. (Option 1) Sleeping on the floor may be outside the client's normal behavior but does not meet the criteria for involuntary admission. (Option 4) Possession of marijuana does not meet the criteria for involuntary admission. (Option 5) The diagnosis of a mental illness alone does not justify the need for involuntary commitment. Educational objective: Clients with a mental illness have the right to refuse treatment, including inpatient hospitalization. Clients can be involuntarily admitted for psychiatric treatment if they pose an imminent danger to themselves or others or if they are gravely disabled and unable to meet their own basic needs. Management of Care

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? 1. Acknowledges poor interpersonal skills 2. Identifies new coping mechanisms 3. Increases caloric intake to gain weight 4. Verbalizes sources of conflict and anger

3 Anorexia nervosa is an eating disorder characterized by distorted body image, profound fear of weight gain, a strong desire to be thin, and being unwilling to maintain a healthy body weight. The client engages in behaviors to lose weight, including not eating, purging, extreme exercise, and use of laxatives and diet pills. Psychosocial issues leading to anorexia are the focus of ongoing therapy, usually on an outpatient basis. However, certain criteria require hospitalization and include body weight below 75% of ideal, suicidal behavior, or medical conditions resulting from starvation. The priority focuses during inpatient care are the short-term outcomes of restoring caloric intake, promoting gradual weight gain, and treating medical conditions caused by starvation. (Options 1, 2, and 4) Acknowledging poor interpersonal skills, identifying new coping mechanisms, and verbalizing sources of conflict and anger are important but will not be the focus during hospitalization. These long-term outcomes will be addressed during ongoing therapy. Educational objective: Treatment for a client requiring hospitalization for anorexia nervosa should focus on the short-term outcomes of increasing caloric intake, promoting gradual weight gain, and addressing medical conditions caused by starvation. Psychosocial Integrity

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? 1. "It would be helpful if you could look at me while we talk." 2. "We can finish our conversation later; thank you for speaking with me." 3. "What do you see at the door?" 4. "When you don't look at me, I feel like you don't trust me."

3 The goal of therapeutic communication with clients diagnosed with schizophrenia is building trust, self-awareness, reality testing, and self-confidence. The nurse should be aware of client cues that indicate hallucinations (distraction, mumbling, watching a vacant area of the room). This client might be having a visual hallucination, as evidenced by being distracted and grimacing. The nurse must assess for hallucinations that might direct or cause the client to be unsafe or aggressive (eg, suicidal or homicidal themes). It is most therapeutic to ask the client what is being seen, heard, smelled, or felt. Once the specifics of the hallucination are known, the nurse can help the client deal with it. (Option 1) This statement does not help the client now. Later, when the nurse knows exactly what the client is seeing, it might be appropriate to redirect the client to the conversation as a way to ignore the hallucination. (Option 2) Ending the conversation would not be therapeutic as it does not allow the nurse to help the client during the hallucination. (Option 4) This statement is not therapeutic as it addresses the nurse's, not the client's, needs. Educational objective: Communication with a client experiencing a hallucination should first focus on the nature of the hallucination so that the nurse can assess for suicidal or homicidal themes. Psychosocial Integrity

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? 1. "Are you still going to take your business trip?" 2. "It sounds like you are having a difficult time coping with your partner's behavior." 3. "Your partner is most likely doing it for attention, so it's best to just ignore it." 4. "Your partner needs to be seen in the clinic today."

4 Clients diagnosed with borderline personality disorder (BPD) often make suicidal threats, gestures, and attempts. They may use these behaviors to bring about a response when there is a real or perceived risk of abandonment from a significant other. All suicidal behavior should be taken seriously; the client's current self-injurious action needs to be evaluated to assess whether it involved suicidal intent. Clients with BPD have been known to demonstrate years of benign suicide threats and gestures before completing a suicide. Predicting a client's risk for completing a suicide is difficult due to the impulsive nature of the behavior. (Options 1 and 3) The priority is for the client to be evaluated at the clinic due to the diagnosis and risk for suicide. The partner's response to the client's behavior can be discussed later. (Option 2) This is not the priority response; it focuses on the partner's needs rather than the client's. Educational objective: Clients with borderline personality disorder are at very high risk for suicide. Suicidal gestures and attempts must be taken seriously and evaluated for suicidal intent. Psychosocial Integrity

Which statement made by the nurse during a therapy session demonstrates a need for further instruction regarding effective therapeutic communication techniques? 1. "I don't understand what you mean. Can you give me an example?" 2. "It is doubtful the president is out to get you." 3. "Tell me more about the day your child died." 4. "Why did you get so angry when she ignored you?"

4 Therapeutic communication allows the nurse to develop a healthy interpersonal relationship with the client. A "why" question is often avoided as it is viewed negatively by clients and can make them feel defensive about their choices or emotions (Option 4). (Option 1) Asking for an example is asking for clarification and is considered a therapeutic communication technique. (Option 2) Voicing doubt is a therapeutic communication technique that allows the nurse to dispel misconceptions or delusions without directly confronting the client's beliefs. (Option 3) Exploring is a therapeutic communication technique that encourages the client to discuss relevant situations and feelings. If the client chooses not to share information, the nurse should respect that decision and not probe further. Educational objective: For people who are anxious or overwhelmed, a "why" question asked by the nurse is often interpreted as being critical, judgmental, and intrusive. These feelings are damaging to the development of the nurse-client relationship and therapeutic communication. Psychosocial Integrity

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? 1. The client is attempting to maintain self-esteem 2. The client is experiencing delusions of grandeur 3. The client is feeling threatened 4. The client is trying to prevent a panic attack

1 A client with narcissistic personality disorder (NPD) exhibits a recurrent pattern of grandiosity, need for admiration, and lack of empathy. Clients with NPD may project a picture of superiority, uniqueness, and independence that hides their true sense of emptiness. From a psychodynamic perspective, individuals with NPD have a fragile and damaged ego resulting from a childhood environment that fostered a sense of inferiority, poor self-esteem, and severe self-criticism. Narcissistic characteristics develop as a way to regulate self-esteem and protect the ego from further psychic injury. (Option 2) Delusions of grandeur are experienced by clients with a psychotic disorder; NPD is a personality disorder. (Option 3) Clients with NPD may feel threatened if criticized or if others do not meet their emotional demands. However, this is not the best explanation of the clinical characteristics associated with NPD. (Option 4) Panic attacks are characteristic of clients with an anxiety disorder, not NPD. Educational objective: The clinical characteristics of narcissistic personality disorder can best be explained as an attempt to maintain a fragile self-esteem that was damaged during childhood due to an environment that was highly critical, demanding, and fostered a sense of inferiority. Psychosocial Integrity

The nurse at a mental health clinic is performing a suicide risk screening on four clients experiencing depression. Which client does the nurse recognize as being most at risk for suicide? 1. Divorced male client with Parkinson disease who was recently laid off from his job 2. Married female client with breast cancer whose daughter is going through a divorce 3. Married male client, newly retired, who is active in community outreach programs 4. Newly divorced female client with type 2 diabetes who has custody of 3 children

1 A suicide screening considers demographics, mental and physical health history, support systems, coping strategies, family history of suicide, previous attempts, and behavioral patterns. In addition to depression, the divorced male client with Parkinson disease and recent job loss is the most at risk for suicide, with 5 risk factors (Option 1). (Option 2) The client who has depression and breast cancer has 2 known risk factors. The daughter's divorce may be a significant loss or stressor, adding another risk factor. However, marriage is a protective factor against suicide. (Option 3) The recently retired male client who is depressed has 3 risk factors. However, marriage and community involvement are protective factors. (Option 4) The client with chronic illness (eg, type 2 diabetes) who is recently divorced has 3 risk factors (including depression). However, custody of children is a protective factor. Educational objective: A suicide screening considers demographics (eg, age, marital status, gender), mental and physical health history, support systems, coping strategies, family history of suicide, previous attempts, and behavioral patterns. Psychosocial Integrity

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? 1. "I know you are frightened, but I do not see a man in your room." 2. "I'll make the bad man go away." 3. "Let's go into the dayroom and play checkers." 4. "Your illness is making you hallucinate."

1 An important step toward self-management of hallucinations is for the client to recognize that the hallucinations are not real. When a client is experiencing hallucinations, the nurse needs to reinforce reality and acknowledge how the client may be feeling. The nurse can point out his/her own perceptions without denying the client's experience. It is nontherapeutic to argue with or challenge the client about the hallucination, saying, for example, "How could a man get into your room? This is a locked hospital unit." Examples of additional therapeutic responses to a client who is experiencing hallucinations include the following: - "I don't see anything, but I understand that what you are seeing may be very upsetting to you." - "I understand that you are worried about the voices you are hearing. They are a part of your disease and not real." - "I know the voices seem real to you and may be scary. I do not hear the voices." (Option 2) This response reinforces the hallucination and does not present reality to the client. (Option 3) This response ignores what the client is experiencing and does nothing to reduce the client's feeling of discomfort. (Option 4) This response provides an explanation for the client's experience but does not acknowledge the client's feelings or reinforce reality. Educational objective: The most therapeutic response to a client experiencing hallucinations presents reality and acknowledges how the client may be feeling. This approach promotes self-management by helping the client recognize that the hallucinations are not real.

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? 1. A board game with a staff member 2. Participation in a group songfest 3. Planning a unit picnic 4. Playing Bingo with other clients

1 Clients with schizophrenia have difficulty initiating and maintaining social interactions with other people. The nurse can facilitate interpersonal functioning by providing one-on-one interaction in which the client can practice basic social skills in a non-threatening way. Once the client feels more comfortable, the nurse can encourage participation in activities that require some interaction with others. Impaired social interaction is one of the negative symptoms of schizophrenia; others include the following: - Inappropriate, flat, or bland affect, and apathy - Emotional ambivalence, disheveled appearance - Inability to establish and move toward goal accomplishment - Lack of energy, pacing and rocking, odd posturing - Regressive behavior, inability to experience pleasure - Seeming lack of interest in the world and people It is the negative symptoms of schizophrenia that affect a client's ability to establish personal relationships and manage day-to-day social interactions. The positive symptoms of schizophrenia (hallucinations, delusions, thought impairment) often improve with psychotropic medications; negative symptoms tend to persist even with medication. Psychosocial and supportive treatment, including psychotherapy, education, behavioral training, cognitive therapy, and social skills therapy, may be beneficial in improving the quality of life for clients with schizophrenia. (Option 2) The client may not be ready for a group activity. However, due to the limited nature of interaction in a group songfest, it would be appropriate when the client is feeling more comfortable being closer to other people. (Option 3) The client is not ready for this activity. (Option 4) This activity requires interaction with others; the client is not ready for this type of activity. Educational objective: Negative sympt

A client with schizophrenia is started on clozapine. Which periodic measurements take priority in this client? 1. Complete blood count and absolute neutrophil count 2. ECG and blood pressure 3. Fasting blood glucose and fasting lipid panel 4. Height, weight, and waist circumference

1 Clozapine (Clozaril) is an atypical antipsychotic medication used to treat schizophrenia that has not responded to standard, more traditional treatment. Clozapine is associated with a risk for agranulocytosis (a potentially fatal blood disorder causing a dangerously low WBC count) and is therefore used only in clients with treatment-resistant schizophrenia. A client must have a WBC count of ≥3500/mm3 (3.5 × 109/L) and an absolute neutrophil count (ANC) of ≥2000/mm3 (2 × 109/L) before starting clozapine, so it is critical to obtain a baseline complete blood count and ANC. Because agranulocytosis is reversible if caught early, the client's WBC count and ANC must also be monitored regularly throughout the course of clozapine therapy (initially once a week) (Option 1). Clients should also contact the health care provider immediately if they develop fever or sore throat, which can indicate infection due to neutropenia. (Option 2) ECG and blood pressure monitoring is performed before therapy initiation and periodically during therapy because prolonged QT interval and orthostatic hypotension are potential side effects of clozapine; however, agranulocytosis poses a more significant danger to the client. (Options 3 and 4) Hyperglycemia, dyslipidemia, and weight gain are potential side effects of clozapine therapy but are not as serious as agranulocytosis. Educational objective: Agranulocytosis, a serious adverse effect of clozapine, is potentially fatal. Pretreatment assessment and ongoing monitoring of WBC and absolute neutrophil counts are critical. Clients should contact the health care provider if they develop fever or sore throat, which can indicate infection due to neutropenia. Pharmacological and Parenteral Therapies

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? 1. Denial and projection 2. Rationalization and depression 3. Regression and displacement 4. Sublimation and reaction formation

1 Defense mechanisms are strategies or responses, usually unconscious, used by individuals to distance themselves from a full awareness of unpleasant thoughts, internal conflicts, and external stresses. Defense mechanisms protect the ego from threatening thoughts and anxiety. Denial is the refusal to accept the reality of threatening situations, or painful thoughts, feelings, or events. It is the most frequent defense mechanism used by clients with alcoholism; the client may deny that drinking is a significant problem and that any issues or problems can be handled alone. This client is also using projection by saying that the spouse should be hospitalized; projection involves placing one's own thoughts, feelings, or impulses onto someone else. (Options 2, 3, and 4) Rationalization, regression, displacement, sublimation, and reaction formation are not the primary defense mechanisms used by the client. This client displays no symptoms of depression. Educational objective: The most common defense mechanism used by persons with alcoholism is denial, the refusal to accept the reality of threatening situations, or painful thoughts, feelings, or events. Projection involves placing one's own thoughts, feelings, or impulses onto someone else.

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? 1. "Functional disorder is a general diagnosis for a genuine medical issue that medical science does not yet fully understand." 2. "I am very sorry to hear this, but are you sure that's what he meant?" 3. "The health care provider does not know what he's talking about. I'll give you the information my health care provider used." 4. "Why do you think he said that?"

1 Educate clients when there is a clear medical misunderstanding. Epilepsy and migraines are examples of functional disorders described for centuries before medical science allowed for a provable diagnosis or development of an effective treatment. (Option 2) Expressing an apology is acceptable if it is genuine, but questioning the client using words that could be construed as patronizing is not the best method. (Option 3) Casual accusations of incompetence regarding other personnel are unprofessional and can result in legal consequences. A nurse who directly observes a medical error or impairment of a colleague must report the facts to the nursing administration for formal investigation. (Option 4) Exploring the issue is an unnecessary step when education could quickly resolve the problem. Educational objective: Functional disorders are currently undiagnosable medical issues and should not be confused with psychosomatic illness, attention-seeking behavior, or malingering. Psychosocial Integrity

The new nurse is providing teaching to a client scheduled for electroconvulsive therapy (ECT). What information given by the new nurse would cause the charge nurse to intervene? 1. "Be sure to take your valproic acid prior to the procedure." 2. "Do not drive during the course of ECT treatment." 3. "Temporary confusion is common immediately after treatment." 4. "You should avoid eating 8 hours prior to the procedure."

1 Electroconvulsive therapy (ECT) induces a generalized seizure by passing an electrical current through electrodes applied to the scalp. Although the exact mechanism is unknown, 15-20-second seizures are proven effective in treating mood disorders (eg, major depression, bipolar disorder) and schizophrenia. Client teaching includes: - NPO status is required for 6-8 hours prior to treatment except for sips of water with medications (Option 4). - Anesthesia (eg, methohexital, propofol) and a muscle relaxant (eg, succinylcholine) will be administered; clients are unconscious and feel no pain during the procedure. - Driving is not permitted during the course of ECT treatment (Option 2). - Temporary memory loss and confusion in the immediate recovery period are common side effects of ECT (Option 3). Post-treatment nursing care includes monitoring vital signs, ensuring a patent airway, assessing mental status, and providing frequent reorientation during periods of postictal confusion. (Option 1) Valproic acid (Depakote) is an anticonvulsant that is also prescribed for bipolar disorder; therefore, it would prevent the therapeutic effect of ECT. Any prescribed anticonvulsants should be discontinued prior to ECT. Educational objective: Electroconvulsive therapy (ECT) uses an electrical current applied to the scalp to induce a generalized seizure in an anesthetized client. Prior to the procedure, the client should be NPO and not take anticonvulsant medications. Temporary confusion and memory loss are common after the procedure. Clients should be instructed not to drive during the course of ECT treatment. Reduction of Risk Potential

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 with you." What is the priority action for the client's nursing care plan? 1. Assign different staff members to care for the client each day 2. Continue assigning the client's stated preferred nurse to care for the client 3. Frequently reassure the client that all staff members are competent in their jobs 4. Reinforce unit rules and consequences of inappropriate behaviors

1 Individuals with borderline personality disorder (BPD) live in fear of rejection and abandonment. To avoid abandonment, they use manipulation and control, often unconsciously, to prevent a person from leaving. The manipulative behavior may be of a positive nature, such as the use of flattery, or a negative nature, such as distancing from the other person. An individual with BPD may also engage in self harm or suicidal behaviors in an attempt to gain attention from the other person and keep that person from leaving. For this client, the nursing care plan must include the assignment of different staff members. This will help diminish the client's dependence on a particular individual and help the client learn to relate to more than one person. (Option 2) Continuing to assign the client's stated preferred nurse will reinforce the manipulative behavior and the need to cling to one person. (Option 3) Simply telling the client about staff competency will not facilitate behavior change. The client is engaging in this behavior as a protection against abandonment. (Option 4) It is important to reinforce unit rules and the consequences of inappropriate behaviors. However, this is not the best action to address the client's attempt to manipulate the staff. Educational objective: Clients with borderline personality disorder, in an attempt to prevent abandonment and control their environment, may flatter and cling to one staff member while making derogatory remarks about others. The best nursing action is to rotate staff members assigned to care for the client.

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? 1. Improved ability to perform activities of daily living 2. Indications that disease progression has stopped 3. Rapid improvement in cognitive functioning 4. Reversal of the disease

1 Memantine is used to ease the symptoms of moderate to severe Alzheimer disease (AD), thereby improving the quality of life for clients and caregivers. Memantine is an N-methyl-D-aspartate (NMDA) antagonist that works by binding to NMDA receptors, blocking the brain's NMDA glutamate pathways, and protecting brain cells from overexposure to glutamate (excess levels of glutamate contribute to brain cell death). Clients with moderate to severe AD may experience improvement in: > Cognition - memory, thinking, language > Daily functioning - dressing, bathing, grooming, eating > Behavioral problems - agitation, depression, hallucinations (Option 2) Memantine delays but does not stop progression of some symptoms of moderate to severe AD. (Option 3) Memantine does not cause rapid improvement of cognitive functioning; it usually takes weeks or months before such improvement is noticeable. (Option 4) Memantine does not reverse the degenerative process of AD. Educational objective: Memantine is a medication used in the treatment of moderate to severe Alzheimer disease (AD). It slows the progression of AD symptoms, and improvement may be seen in the client's behavior, cognitive functioning, and ability to perform activities of daily living. Pharmacological and Parenteral Therapies

A client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting. The nurse enters the room to remind the client that breakfast will be served in the dining room in 20 minutes. The client says, "I'm not hungry and I don't feel like doing anything." What is the best response by the nurse? 1. "I will help you get ready; then we can walk to the dining room together." 2. "I'll have breakfast brought to your room." 3. "It's okay. You can join us when you are ready." 4. "You'll feel better when you get up."

1 Reduced appetite and low energy level are common clinical findings in major depressive disorder. The lethargy accompanying the depressed mood makes it difficult for a client with this diagnosis to even get up and out of bed. Personal hygiene and grooming are neglected, and there is no desire to interact with others. The client needs direction and structure in performing activities of daily living (ADLs); waiting for the client to feel more energetic and initiate activity and interaction on one's own is not helpful. Assisting the client with ADLs helps convey a sense of caring, provides an opportunity for interaction with the nurse, and helps raise the client's self esteem. (Option 2) This action reinforces the client's desire to stay in the room and is not therapeutic. (Option 3) This response is non-therapeutic; the client needs assistance with ADLs. (Option 4) Clients with depression often do feel better after even minimal exercise and activity. However, this response does not give the client direction or structure. Educational objective: Clients with low energy, lethargy, or fatigue associated with major depressive disorder need structure and direction in performing basic ADLs, including personal hygiene and grooming. The nurse needs to provide assistance to the client in completing ADLs and in initiating social interaction with others. Psychosocial Integrity

The nurse is caring for a client with bulimia nervosa. Which is the most important time for the nurse to monitor the client's behavior? 1. During 1-2 hours after each meal 2. During every meal 3. During the evening meal 4. During the overnight hours

1 The eating behavior of a client with bulimia nervosa typically consists of binge eating followed by an inappropriate behavior to prevent weight gain, such as self-induced vomiting, exercise, and/or excessive use of laxatives. Although it is important to provide one-on-one supervision to a client with bulimia during every meal, it is most important to monitor the client's activities for 1-2 hours after each meal to prevent self-induced vomiting (Option 2). Clients with bulimia nervosa will often go to extreme lengths to engage in purging activity, especially at the beginning of a treatment program, as a way of gaining control. After mealtime, it may be necessary to restrict clients to the dayroom or a specified area with no bathroom privileges for a set period. Clients will also need to be monitored at all times for engaging in excessive exercise. (Option 3) Clients need to be monitored during every meal, not just during the evening meal. (Option 4) Secretive bingeing and purging during the night or before bedtime are not uncommon for a client with bulimia nervosa. However, in a structured inpatient environment, the client would not have access to excessive amounts of food. Educational objective: Clients with bulimia nervosa should be supervised during every meal. However, it is most important to monitor the postprandial activity of these clients to prevent self-induced vomiting as a way to prevent weight gain.

A 60-year-old client wanders away during halftime at a football game and is found 48 hours 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? 1. Assess vital signs 2. Contact family members 3. Encourage the client to recall recent events 4. Perform a mental status assessment

1 This client is experiencing amnesia of undetermined origin. The cause could stem from a medical condition, substance abuse, traumatic brain injury, cognitive disorder such as dementia, or psychiatric condition such as dissociative fugue. Regardless of the diagnosis, the priority nursing action is to assess the client's physical status. This client has been wandering for 2 days and cannot recall previous locations, arriving at the present location, and the timetable involved. It is highly probable that the client is dehydrated and fatigued. It is most important to assess the client's physical needs and implement interventions to stabilize the physiologic condition before assessing psychosocial status and needs. (Option 2) It is appropriate to contact this client's family members. However, this is not the priority nursing action. (Option 3) This client may never be able to remember the events of the past 2 days. Encouraging a client to remember something when there is no sign of recollection may only increase client frustration. (Option 4) A mental status examination is an important component of the nurse's assessment. However, it is not the priority assessment. Educational objective: Assessment of a client's physiologic status and needs is the priority nursing action when the client is suffering from amnesia with no recollection of where he has been or what he has been doing for a period of time. Interventions need to be implemented to stabilize the client physically before psychosocial needs are addressed. Reduction of Risk Potential

The nurse is reviewing the records of an adolescent client. Which findings suggest that the client may need referral for depression screening? Select all that apply. 1. Client has had school disciplinary issues due to absenteeism and angry outbursts 2. Client has lost approximately 8 lb (3.64 kg) over the last 3 weeks without trying 3. Client is often found sleeping during class or activities 4. Client quit sports despite receiving previous athletic awards and trophies 5. Client voices concern about appearance related to facial acne

1, 2, 3, 4 Adolescent clients are at increased risk for developing depressive and anxiety-related mood disorders as they begin to identify their role in adult life and develop new personal relationships. However, they frequently report vague somatic symptoms (eg, headache, stomachache) and may exhibit an irritable or cranky mood rather than a sad or dejected mood. Signs of depression in adolescent clients include: - Hypersomnolence or insomnia; napping during daily activities (Option 3) - Low self-esteem; withdrawal from previously enjoyable activities (Option 4) - Outbursts of angry, aggressive, or delinquent behavior (eg, vandalism, absenteeism); inappropriate sexual behavior (Option 1) - Weight gain or loss; increased food intake or lack of interest in eating (Option 2) Depression is also a significant cause of suicide in adolescents. (Option 5) Adolescent clients begin to become more aware of body image and may express concern regarding their appearance. It is normal for clients in this age group to experience insecurity about their appearance (eg, acne, body hair). These insecurities do not correlate with the onset of a depressive disorder. Educational objective: Adolescent clients with depression frequently report vague somatic symptoms (eg, headache, stomachache) and may exhibit an irritable or cranky mood rather than a sad or dejected mood. In addition, changes in sleep patterns; low-self esteem; withdrawal from previously enjoyable activities; outbursts of aggressive or delinquent behavior; and precipitous weight changes may indicate the onset of a depressive disorder.

The nurse plans care for a client newly admitted with obsessive-compulsive disorder who is repeatedly counting magazines in the commons room. Which of the following should the nurse include in the initial plan of care? Select all that apply. 1. Assist the client to identify circumstances that increase anxiety 2. Provide positive feedback when the client attends a group activity 3. Refrain from judgmental comments about counting magazines 4. Remove the magazines from the commons room 5. Teach the client how to use the technique of thought stopping

1, 2, 3, 5 Obsessive-compulsive disorder is characterized by obsessions (ie, persistent and intrusive thoughts, impulses, or images) and compulsions (ie, ritualistic, repetitive behaviors performed to reduce anxiety or prevent an adverse event). Clients are aware that such behavior is irrational, but performing the actions provides relief, which compels them to continue. Initially, nursing care includes: - Assisting the client to identify circumstances that increase anxiety (Option 1) - Offering positive feedback when the client engages in nonritualistic behavior (eg, group activities, board games) (Option 2) - Remaining nonjudgmental and empathetic and using reflective communication (Option 3) - Cognitive-behavioral therapy (eg, thought stopping) (Option 5) (Option 4) Suddenly denying the client the ability to perform the ritualistic activity can cause panic-level anxiety. Instead, the nurse should gradually limit the time allotted to the ritualistic behavior, once the client is equipped with new coping mechanisms. Educational objective: Obsessive-compulsive disorder is characterized by persistent, intrusive thoughts (obsessions) and behaviors performed ritualistically and repetitively to try to reduce anxiety (compulsions). Nursing care includes assisting the client to identify anxiety-producing situations, allowing time for the ritualistic behavior (initially), remaining nonjudgmental, offering positive feedback, and providing cognitive-behavioral therapy.

The emergency department registered nurse is triaging a client for the risk of suicide. The client had thoughts of self-injury yesterday but is not sure today. Which of the following would be considered a known risk factor for suicide in this client? Select all that apply. 1. Constantly hearing voices saying client is worthless 2. Deliberately took an overdose 1 year ago 3. Has a gun at home 4. Married with 3 children 5. Participation in religious activities 6. Unemployed and unable to find a job

1, 2, 3, 6 The mnemonic SAD PERSONS uses known risk factors and the concept of their accumulation to help predict who is at a higher risk of committing suicide. S - Sex (men kill themselves more often than women; women make more attempts) A - Age (teenagers/young adults, age >45) D - Depression (and hopelessness) P - Prior history of suicide attempt E - Ethanol and/or drug abuse R - Rational thinking loss (hearing voices to harm self) S - Support system loss (living alone) O - Organized plan; having a method in mind (with lethality and availability) N - No significant other S - Sickness (terminal illness) This client has a lethal option readily available (Option 3), a history of a prior attempt (Option 2), and loss of rational thinking (Option 1). Unemployed and unskilled individuals are also at risk (Option 6). The client should be triaged as being at high risk and appropriate protective measures instituted. (Options 4 and 5) Social support/family connectedness, pregnancy, parenthood, and religion and participating in religious activities are protective factors against suicide. Educational objective: Elderly white men, severe depression, living alone, prior or family history of suicide attempt, substance abuse, rational thinking loss, organized plan, unemployed or unskilled, and terminal illness are the risk factors for suicide. Social support/family connectedness, pregnancy, parenthood, and religion and participating in religious activities are protective factors against suicide.

The mental health nurse is planning care for a client newly admitted with dissociative identity disorder. Which interventions will the nurse include? Select all that apply. 1. Develop a trusting relationship with each of the alternate identities 2. Encourage the client to journal about feelings and dissociation triggers 3. Explain to the client in detail the events of missing memories and lost time 4. Listen for expressions of self-harm from the alternate identities 5. Teach grounding techniques such as deep breathing to hinder dissociation

1, 2, 4, 5 Dissociative identity disorder is a condition in which 2 or more identities alternately control the client's behavior. The alternate identities likely develop as a response to abuse or traumatic events and serve to protect the client from stressful memories. The client may not be aware of the alternate identities and may be confused by "lost time" and gaps in memory. Switching between identities occurs as a reaction to stress and individual triggers. The goal of treatment is to integrate the identities into one personality while maintaining safety. The client should journal about feelings and dissociation triggers and use a grounding technique (eg, deep breathing, rubbing a stone, counting coins) to counter dissociative episodes (Options 2 and 5). Identities may be volatile and should be monitored for indications of harm to self or others (Option 4). The nurse should attempt to form trusting, therapeutic relationships with each identity to explore feelings and facilitate identity integration (Option 1). (Option 3) Dissociation and memory gaps are protective mechanisms. Forcing the client to hear or attempt to recall memories may result in distress and regression. Allow clients to recall memories at their own pace. Educational objective: When caring for clients with dissociative identity disorder, the nurse should establish relationships with each identity, listen for expressions of self-harm, allow clients to recall memories at their own pace, encourage journaling about feelings and dissociation triggers, and teach grounding techniques to counter dissociative episodes. Psychosocial Integrity

The home health nurse visits a 75-year-old client with mild Alzheimer dementia who recently moved in with a caregiver. Which observations would cause the nurse to suspect neglect? Select all that apply. 1. Client breaks eye contact when discussing caregiver 2. Client has lost 8 lb (3.63 kg) in the previous 4 weeks 3. Client is wearing clothing that is out of style 4. Client's eyeglasses have been visibly broken for 1 month 5. Client's prescription medication is expired

1, 2, 4, 5 Elder abuse or neglect occurs when caregivers intentionally or unintentionally fail to meet the older adult client's physical, emotional, or social needs. Approximately 1 in 10 older adult clients are victims of physical, psychological, or sexual abuse by a caregiver. Commonly neglected necessities include water, food, medication, hygiene, and clothing. The client's living conditions may be unsafe or have inadequate access to public utilities. Objective findings consistent with abuse or neglect include: - Dehydration, malnutrition, and weight loss (Option 2) - Poor hygiene, soiled bedding or clothing, and pressure ulcers - Missing/broken assistive devices (eg, eyeglasses); medications withheld or expired (Options 4 and 5) Clients who have experienced abuse or neglect may find the situation difficult to discuss and display apprehension, restlessness, withdrawal, poor eye contact, shame, and despair (Option 1). The client may also deny or minimize the extent of the abuse out of fear or embarrassment. (Option 3) Clothing that is out of style is not indicative of neglect. However, soiled clothing or clothing unsuitable for the weather (eg, no jacket on a cold day) does indicate possible neglect. Educational objective: Manifestations of abuse or neglect in an older adult may include development of pressure ulcers, poor hygiene, dehydration, malnutrition, weight loss, soiled bedding/clothing, missing/broken assistive devices, and missing or expired medications. Psychosocial Integrity

The nurse performs an initial assessment on a client with suspected post-traumatic stress disorder. Which assessments would support this diagnosis? Select all that apply. 1. Difficulty concentrating 2. Feeling detached from others 3. Feeling lethargic and apathetic 4. Flashbacks of the traumatic event 5. Persistent angry, fearful mood

1, 2, 4, 5 Post-traumatic stress disorder (PTSD) may occur in people who have seen or experienced a terrifying, traumatic event (eg, war, tornado, rape, plane crash). There are 3 categories of PTSD symptoms: 1. Reexperiencing the traumatic event Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or strong physical reactions to event reminders (eg, rapid, pounding heart; gastrointestinal distress; diaphoresis) (Option 4) 2. Avoiding reminders of the trauma Examples include avoidance of activities, places, thoughts, or other triggers that could serve as reminders; feeling detached and emotionally numb; loss of interest in life; inability to set goals; and amnesia about important details of the event (Option 2) 3. Increased anxiety and emotional arousal Examples include insomnia, irritability, outbursts of rage, persistent anger and/or fear, difficulty concentrating, hypervigilance, and exaggerated startle response (Options 1 and 5) (Option 3) Persons with PTSD are typically restless and hypervigilant and have trouble falling or staying asleep. Educational objective: A person suffering from post-traumatic stress disorder experiences 3 categories of symptoms: reexperiencing the traumatic event, avoiding reminders of the trauma, and hyperarousal.

The nurse is presenting an in-service educational session on child abuse and neglect to a class of certified home health aides. Which of the following statements should the nurse include when discussing the characteristics of the typical perpetrator of child abuse? Select all that apply. 1. "Abusers often have a history of growing up in an environment of domestic violence." 2. "Abusers often have a history of substance abuse." 3. "Child abusers always present as being agitated or out of control." 4. "Most child abusers have a sense of low self-esteem." 5. "Teenage parents are particularly vulnerable to abusing their children."

1, 2, 4, 5 Typical characteristics of child abuse perpetrators include: - Unrealistic expectations of the child's performance, behavior, and/or accomplishments; overly critical of the child - Confusion between punishment and discipline; having a stern, authoritative approach to discipline - Having to cope with ongoing stress and crises such as poverty, violence, illness, lack of social support, and isolation (Option 1) - Low self-esteem—a sense of incompetence or unworthiness as a parent (Option 4) - A history of substance abuse; use of alcohol or drugs at the time the abuse occurs (Option 2) - Punitive treatment and/or abuse as a child - Lack of parenting skills, inexperience, minimal knowledge about child care and child development, and young parental age (Option 5) - Resentment or rejection of the child - Low tolerance for frustration and poor impulse control - Attempts to conceal the child's injury or being evasive about an injury; shows little concern about the child's injury (Option 3) Child abusers are not easily identified by appearance; they often appear calm and well in control but may have violent outbursts, typically in private. Educational objective: Child abusers often have a history of growing up in an environment of domestic violence and have a sense of low self-esteem. History of substance abuse is also a risk factor. Teenage parents are particularly vulnerable to abusing their children.

Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply. 1. Amenorrhea 2. Fluid and electrolyte imbalances 3. Heat intolerance 4. Presence of lanugo 5. Refusal to exercise 6. Weight loss of 25% below normal weight

1, 2, 4, 6 Anorexia nervosa is an eating disorder common among adolescents and young adults. Clinical manifestations of anorexia nervosa include: 1. Fear of weight gain - clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands and erosion of tooth enamel. 2. Fluid and electrolyte imbalance - excessive vomiting can cause hypokalemia and metabolic alkalosis 3. Amenorrhea - clients are often amenorrheic due to decreased body fat (low estrogen) 4. Decreased metabolic rate - severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance 5. Lanugo (fine terminal hair) can be seen in extreme cases Manifestations of anorexia nervosa will resolve after the weight loss is corrected, although the recovery process can take several months. (Option 3) Anorexia nervosa manifests as cold intolerance. (Option 5) Anorexia nervosa manifests as lengthy and vigorous exercise. Educational objective: The clinical manifestations of anorexia nervosa include extreme weight loss, amenorrhea, bradycardia, cold intolerance, dry skin, and lanugo. Life-threatening complications, such as cardiac arrhythmias associated with hypokalemia, may develop.

Which of the following actions would the nurse include in planning care for a client hospitalized for bipolar disorder, acute manic episode? Select all that apply. 1. Assign the client to a private room 2. Choose clothing for the client 3. Have the client be in charge of planning an outing for the unit 4. Have the client join other clients in the dining room for meals 5. Have the client participate in physical exercise with a staff member 6. Include the client in group therapy sessions

1, 2, 5 In developing a care plan for a client experiencing acute mania, the nurse is aware that an acute manic episode is characterized by the following: - Excessive psychomotor activity - Euphoric mood - Poor impulse control - Flight of ideas, non-stop talking - Poor attention span, distractibility - Hallucinations and delusions - Insomnia - Wearing bizarre or inappropriate clothing, jewelry, and makeup - Neglected hygiene and inadequate nutritional intake The care plan for a client experiencing an acute manic episode includes the following: - Reduction of environmental stimuli > Providing a quiet, calm environment > Limiting the number of people who come in contact with the client > One-on-one interactions rather than group activities > Low lighting - A structured schedule of activities to help the client stay focused - Physical activities to help relieve excess energy - Providing high-protein, high-calorie meals and snacks that are easy to eat - Setting limits on behavior (Option 3) The client is easily distractible and would not be able to focus on planning an activity. (Option 4) The client who is experiencing an acute manic episode needs reduced environmental stimuli. Eating with other clients in the dining room would be too stimulating and could exacerbate psychomotor activity. (Option 6) The client with acute mania is not ready to participate in group activities. Educational objective: The nursing care plan for clients with acute mania includes providing a quiet, structured, non-stimulating environment; engaging the client in one-on-one activities and physical activity; limiting contact with other people; and providing foods of high nutritional value that are easy to eat. Psychosocial Integrity

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? Select all that apply. 1. "How has this situation affected your relationships with family and friends?" 2. "It is important to focus on coping strategies and not dwell on the event." 3. "It is normal to experience difficult symptoms after a traumatic event." 4. "Please tell me about your current use of alcohol and any drugs." 5. "Share with me any thoughts or plans of self-harm that you have had."

1, 3, 4, 5 Acute stress disorder (ASD) occurs following a traumatic or extremely stressful event. ASD is characterized by intrusive memories of the event, negative mood, dissociative symptoms (eg, altered sense of reality), and arousal and reactivity symptoms (eg, hyperactive sensory state, sleep disturbances, difficulty concentrating, easily startled). If these symptoms continue beyond a month after the event, the diagnosis becomes post-traumatic stress disorder. Nursing interventions for a client with ASD include: - Assessing for ideas and plans to commit self-harm (Option 5) - Assessing for ineffective coping (eg, use of drugs and alcohol) (Option 4) - Assessing impact of ASD on the client's job performance, relationships, sleep pattern, and ability to perform activities of daily living (Option 1) - Explaining that feelings and/or symptoms occurring after traumatic events are normal, as this can help alleviate the client's anxiety (Option 3) - Exploring coping strategies used in previous stressful situations (Option 2) The client should be encouraged to discuss the traumatic event. As part of the debriefing process, the nurse should acknowledge and validate the associated feelings and behaviors. Educational objective: Clients with acute stress disorder (ASD) should be encouraged to discuss the traumatic event and explore the associated feelings. The nurse should validate the client's feelings; assess risk for self-harm and ineffective coping (eg, drug and alcohol use); and evaluate the impact of ASD on the client's sleep, occupation, and relationships.

The home health nurse assesses a child and suspects that the child is being abused. Which of the following questions are appropriate for the nurse to ask the caregiver? Select all that apply. 1. "How would you describe your child's usual behavior at home?" 2. "These bruises seem excessive and suspicious. How did they happen?" 3. "What forms of discipline do you use with your child?" 4. "When you are stressed, what coping mechanisms do you use?" 5. "Who watches your child when you are at work?"

1, 3, 4, 5 When the nurse suspects that a child may be the victim of child abuse, the parent or caregiver should be questioned, and all possibilities (eg, alternate caregivers) should be explored to find the source of the abuse. If possible, the interview should be done without the child present. The nurse should remain supportive and empathetic and convey a nonjudgmental, nonthreatening attitude, avoiding words such as "abuse" and "violence." Open-ended questions are less threatening and provide more detailed responses. Information to gather includes: - Caregiver's perspective on the child's behavior (Option 1) - Methods of discipline used with the child (Option 3) - Routine caregivers for the child - Caregiver stress, coping, and support systems (Option 4) - Person or persons who care for the child when regular caregivers are away (Option 5) (Option 2) Use of the words "excessive" and "suspicious" to describe the child's bruising conveys judgment. This may cause the caregiver to become defensive and limit the nurse's ability to establish trust and find the source of the abuse. Educational objective: When child abuse is suspected, the nurse should convey empathy and support when questioning a caregiver while maintaining a nonjudgmental, nonthreatening attitude. Open-ended questions are less threatening and provide more detailed responses. Psychosocial Integrity

The nurse in the outpatient treatment facility evaluates the plan of care for a client with alcohol use disorder. Which of the following client statements indicate positive progress toward recovery? Select all that apply. 1. "Drinking led to my divorce and the loss of my children." 2. "I am in control now; I drink only on special occasions." 3. "I will have no desire to drink once I get over my divorce." 4. "My focus is now on fitness training and going back to college." 5. "When cravings occur, I call my Alcoholics Anonymous sponsor."

1, 4, 5 Alcohol use disorder, or alcoholism, occurs when alcohol is consumed in excess over time until dependence develops, causing withdrawal to occur when alcohol is not consumed. Alcohol consumption can become the client's sole focus, which negatively impacts the social, familial, and occupational aspects of the client's life. After the detoxification period, the plan of care includes a goal-setting process to progress the client toward total abstinence from alcohol. Goals for client recovery include: - Expressing accountability for previous behavior, including how abusing alcohol has impacted personal life (Option 1) - Using insight to face reality and overcome rationalization and projection - Using coping skills (eg, support groups, relaxation techniques) to improve reactions to stressful situations (Option 5) - Setting goals for personal growth and self-worth development and using nonchemical alternatives (eg, fitness training) for stress relief (Option 4) - Maintaining abstinence from alcohol consumption (Option 2) This statement represents denial, a common maladaptive defense mechanism in which substance misuse or addiction is minimized and/or clients deny having a problem with substance use. (Option 3) This statement represents rationalization, a common maladaptive defense mechanism in which the client makes excuses (eg, divorce) to justify substance use. Educational objective: Clients recovering from alcohol use disorder should demonstrate accountability for past behavior and identify the consequences, use insight to face reality, and use coping skills and nonchemical alternatives. The client should also be encouraged to set goals for personal growth.

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? Select all that apply. 1. Allow the client to receive at least 20 minutes of natural sunlight each day 2. Encourage the client to take naps during the day to make up for lost sleep 3. Have the client engage in strenuous physical exercise just before bedtime 4. Spend time with the client in a quiet environment just before bedtime 5. Suggest that the client take a warm bath before going to bed

1, 4, 5 Sleep disturbances are part of the diagnostic criteria for major depressive disorder. Clients may experience insomnia (early in the night, in the middle of the night, or in the early morning hours) or hypersomnia. Long-term treatment with medication alone is not necessarily the best approach to treat insomnia. Nonpharmacological strategies for improving sleep hygiene include: - Avoiding naps throughout the day - Engaging in physical activity or exercise, preferably at least 5 hours before bedtime - Receiving at least 20 minutes of natural sunlight each day, ideally in the morning, to improve sleep patterns - Avoiding caffeinated beverages after noon - Avoiding alcohol and/or smoking at bedtime - Participating in a relaxing activity before bedtime (eg, warm bath, reading, listening to soft music) - Decreasing environmental stimuli; making sure the bedroom is dark, cool, and quiet - Avoiding heavy meals or large amounts of fluids at bedtime - Drinking a cup of warm milk or eating a small amount of carbohydrates before bedtime, which promotes comfort and relaxation to aid sleepiness (Option 2) Napping during the day interferes with normal sleep patterns. (Option 3) Exercising right before going to bed increases brain metabolic activity and wakefulness. Educational objective: Nonpharmacological strategies for improving sleep hygiene include exercising during the day, engaging in a relaxing activity before bedtime, having a relaxing sleep environment, avoiding naps during the day, avoiding caffeine after noon, and receiving at least 20 minutes of sunlight each day.

A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which interventions and strategies? Select all that apply. 1. Desensitization to a specific stimulus or situation 2. Discussing the interpersonal difficulties that have led to the client's psychological problems 3. Helping the client develop insight into the psychological causes of the disorder 4. Relaxation techniques 5. Self-observation and monitoring 6. Teaching new coping skills and techniques to reframe thinking

1, 4, 5, 6 Cognitive behavioral therapy (CBT) can be effective in treating anxiety disorders, eating disorders, depressive disorders, and medical conditions such as insomnia and smoking. These types of disorders are characterized by maladaptive reactions to stress, anxiety, and conflict. CBT requires that the client learn the skill of self-observation and to apply more adaptive coping interventions. CBT involves 5 basic components: - Education about the client's specific disorder - Self-observation and monitoring - the client learns how to monitor anxiety, identify triggers, and assess the severity - Physical control strategies - deep breathing and muscle relaxation exercises - Cognitive restructuring - learning new ways to reframe thinking patterns, challenging negative thoughts - Behavioral strategies - focusing on situations that cause anxiety and practicing new coping behaviors, desensitization to anxiety-provoking situations or events (Option 2) This describes interpersonal psychotherapy. (Option 3) This describes psychodynamic or psychoanalytic therapy. Educational objective: CBT teaches clients to reframe their thought processes and develop new adaptive approaches for coping with anxiety, stress, and conflict. CBT requires that the client learn about the disorder and engage in self-observation and monitoring, relaxation techniques, desensitization activities, and changing negative thoughts.

The school nurse is called to the classroom to assist with a 7-year-old with attention-deficit hyperactivity disorder who is throwing books and hitting the other children. What is the best initial action for the nurse to take? 1. Administer a PRN dose of methylphenidate 2. Ask the child to blow up a balloon 3. Give the child a "time out" in a quiet place 4. Reinforce the consequences of disruptive behaviors

2 A key feature of attention-deficit hyperactivity disorder (ADHD) is hyperactivity; however, some children with ADHD behave aggressively and have difficulty controlling anger, especially when frustrated or if unable to meet demands and challenges. An immediate intervention to help settle an out-of-control child is deep breathing. Taking slow, deep breaths relaxes the body, slows the heart rate, and distracts the child from inappropriate behaviors. Asking the child to blow up a balloon provides an easy mode of distraction and engages the child in a deep breathing exercise. After the child is calm, the nurse and the child can further discuss the disruptive behavior. Nursing interventions include the following: - Stay calm and remove the child from the source of frustration/anger - Assist the child in calming down with deep breathing exercises - Discuss what precipitated the behavior and why the behavior is wrong - Discuss acceptable ways of expressing anger and frustration - Acknowledge that controlling anger is difficult - Provide rewards for appropriate behavior - Discuss the consequences of inappropriate behavior (Option 1) Methylphenidate is not used on a PRN basis; it is administered daily in 2-3 divided doses (or in sustained release form) 30-45 minutes before meals. (Option 3) Isolating the child is punitive and not therapeutic; instead, remove the child from the source of anger. (Option 4) Reminding the child of the consequences of inappropriate behavior is a valid intervention. However, the best action is to help the child calm down and relax first. Educational objective: The priority intervention for a child with ADHD who is engaging in aggressive behavior is to assist the child in calming down and gaining control. Deep breathing exercises are an easy and efficient approach to help the body and m

A nurse is admitting a child and observes multiple irregular bruises. Which action should the nurse take next? 1. Ask parents to leave the room during the admission process 2. Continue with a detailed interview and physical examination 3. Notify the charge nurse and the social worker 4. Promise not to tell anyone if the child reveals abuse

2 A nurse who suspects child abuse should conduct a detailed interview and physical examination to identify potential indicators of abuse (Option 2). In addition to obvious injuries, abused children may show extremes in behavior, including being overly shy, fearful, or even unusually affectionate. Parents should remain present during the admission process and the nurse should observe parent-child interactions for signs of abusive behavior (eg, refusal to comfort, blaming, belittling) (Option 1). Abusive parents may be hostile or uncooperative with the health care team. The nurse should also assess for inconsistencies between the parents' report and the actual findings. (Option 3) The nurse should report findings that indicate abuse to the charge nurse, social worker, and health care provider only after conducting a full history and physical examination. (Option 4) The nurse should not make promises of secrecy to the child or family if abuse is revealed. The child or family should be told that the nurse is required by law to report all abuse. Educational objective: If child abuse is suspected, the nurse should obtain a detailed history, perform a physical examination, and report signs of abuse. Parent-child interaction should be examined closely, and any inconsistencies between a parent's report and the actual findings should be documented.

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? 1. "But you look so thin." 2. "I don't see you that way; you are making progress toward a healthy weight." 3. "If you continue to gain weight at this rate, you will be able to go home soon." 4. "You are not fat; it's all in your imagination."

2 A nursing diagnosis associated with anorexia nervosa is disturbed body image/low self esteem. There is often a large disparity between actual weight and the client's perceived weight. Clients with anorexia nervosa think of themselves as overweight and fat. The nursing care plan should include helping the client develop a realistic perception of weight and body image. The nurse can confront the client about the misinterpretation of body weight by presenting reality without challenging the client's illogical thinking. The client's weight should be discussed in the context of overall health. The nurse also needs to be aware of his/her own reaction to the client's behaviors and statement. It is not uncommon for caregivers and care providers to feel frustrated or even angry when caring for a client with an eating disorder. The nurse must maintain a neutral attitude and approach, avoiding arguing or disagreeing with the client's statements. (Option 1) This response is judgmental, reinforces the idea of "thinness," and does not help the client develop a more realistic body image. (Option 3) Establishing a goal weight is part of the nursing care plan for the client with anorexia nervosa; clients are usually not discharged from inpatient treatment until goal weight is achieved. However, this response does not address the client's misperception of body weight. (Option 4) This response dismisses the client's concern and does not present the reality of the situation. Educational objective: Clients with anorexia nervosa have disturbed body image and see themselves as being fat or overweight even when they are severely underweight or even at a normal body weight. The nurse can help the client develop a more realistic self image by presenting the situation realistically and discussing weight in terms of the client's health.

A 10-year-old client with autism spectrum disorder is hospitalized for a diagnostic workup. Which is the most appropriate nursing action? 1. Encouraging visits by friends to decrease social isolation 2. Giving the client a schedule of daily activities 3. Placing the client in restraints during invasive procedures 4. Providing the client with a variety of toys

2 A structured routine and consistency during hospitalization are critical in the care of clients with autism spectrum disorder (ASD). The nurse should talk with the parent and/or caregiver to determine the client's usual patterns and habits for a typical day at home, including meal times, bath time, and play time. In the unfamiliar and often unpredictable environment of the acute care setting, a schedule of activities can decrease anxiety and help the client with ASD anticipate what will happen next. (Option 1) A common nursing diagnosis associated with ASD is impaired social interaction characterized by unresponsiveness to people. Limiting the number of visitors can help avoid client overstimulation and facilitate a trusting relationship with the caregiver. (Option 3) Invasive procedures may be particularly difficult and painful for clients with ASD due to their hypersensitivity to touch. Strategies such as distraction and being held by parents or caregivers are preferred over the use of restraints. (Option 4) The young client with ASD may be overwhelmed and overstimulated if given too many choices. The best approach is for family members to bring in some of the client's favorite toys. Educational objective: Structure and consistency are crucial when caring for a client with autism spectrum disorder. A daily schedule of activities can decrease anxiety and help the client anticipate what will happen next. Limiting the number of visitors and choices can help avoid overstimulation and enhance communication with the caregiver. Psychosocial Integrity

A 12-year-old with moderate intellectual disability and an intelligent quotient of 45 is hospitalized. What will the nurse recommend as the best recreational activity for this child? 1. Child's favorite stuffed animal 2. Connect-the-dots puzzle book 3. Putting together a 300-piece jigsaw puzzle 4. Writing in a journal about the hospital stay

2 Activities for children with intellectual disabilities should be based on the child's developmental age with consideration given to size, coordination, physical fitness, maturity, likes and dislikes, and health status. A child with moderate intellectual disability: - Has academic skills at about the 2nd grade level and may be able to work in a sheltered workshop - Performs self-care activities with some supervision - Participates in simple activities - May have limited speech capabilities - Appropriate play activities for this child include simple puzzles, coloring books and crayons, modeling clay, watching cartoons or favorite movies, sticker books, playing with a large ball (eg, inflatable beach ball), simple card and board games, and being read to aloud. (Option 1) Most children would like having their favorite stuffed animal while hospitalized, but it is not the best choice for this child. The toy may be comforting but does not offer the child the opportunity to engage in active play. (Option 3) A 300-piece jigsaw puzzle would be too challenging and frustrating for a child with moderate intellectual disability. (Option 4) Keeping a journal about the hospital stay is a more appropriate activity for a child with a higher level of intellectual development (ie, one who has achieved high school level academic skills). Educational objective: Activities for children with intellectual disabilities should be based on developmental age with consideration given to the child's size, coordination, physical fitness, maturity, likes and dislikes, and health status.

The clinic nurse reviews telephone messages left by 4 clients. Which client is the priority to call back first? 1. Client recovering from opioid addiction having cravings after losing job 2. Client with schizophrenia hearing voices advising to harm a neighbor 3. Parent of a client with conduct disorder who refuses to leave a locked room 4. Spouse of a client with depression reporting the client is threatening suicide

2 Auditory hallucinations are the most common form of hallucination, noted by falsely perceived sounds, most often in the form of voices. Command hallucinations are a specific type of auditory hallucination, during which voices instruct the client to perform specific actions, often demanding harm to the client or others. Clients who are alone and experiencing command hallucinations that are homicidal or suicidal in nature require immediate intervention to ensure the safety of themselves and others (Option 2). (Option 1) A client experiencing addiction cravings needs assistance but is not a priority over a client with command hallucinations demanding harm to others. (Option 3) Parents of clients with conduct disorder need guidance and training to appropriately respond to problem behavior; however, this is not an immediate safety risk. (Option 4) A spouse calling about a suicidal client is not the first priority; the client is not alone, and the spouse can call others for help (eg, police, suicide hotline) if necessary while awaiting the nurse's return call. This should be the second returned call. Educational objective: A client who is alone with command hallucinations that are homicidal or suicidal in nature requires immediate intervention to prevent harm. Clients who are homicidal or suicidal but are with another person should be addressed after those who are alone. Management of Care

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? 1. "Perhaps finding a caregiver to care for your spouse at night might be helpful." 2. "Tell me about the care you provide in a typical day and its challenges." 3. "Try not to worry. It's normal to feel overwhelmed when you are stressed." 4. "You seem worried that you won't be able to provide the care that your spouse needs."

2 Caregiver role strain (CRS) is a caregiver's perception of the multifactorial difficulties associated with providing care to another person (usually a family member). The nurse should assess caregivers for signs of physical (eg, fatigue, insomnia, weight loss/gain), emotional (eg, depression, anxiety, anger), and social (eg, isolation, loss of support systems) problems. Monitoring caregivers for CRS is important, as it can have a significant negative impact on their health and well-being. Asking about the nature and requirements of providing daily care allows the caregiver to discuss the demands of providing care and helps the nurse understand stressors and unmet needs (Option 2). This type of inquiry is a therapeutic response that encourages verbalization of thoughts, feelings, and concerns. Assessment of caregiving challenges also helps to identify opportunities for assistance (eg, skills training, support groups) and community resources (eg, home health care, food/nutrition services). (Options 1 and 3) Giving opinions and providing false reassurance are nontherapeutic, discourage nurse-client communication, and do not help identify CRS. (Option 4) Restating client statements can be therapeutic because it shows that the nurse has analyzed what has been said. However, this response does not prompt the client to discuss potential difficulties in providing care. Educational objective: Caregiver role strain is a caregiver's perception of multifactorial difficulties associated with providing care to another person. The nurse should routinely monitor for signs of caregiver role strain (eg, fatigue, depression, isolation) because it can have a significant negative impact on a caregiver's health and well-being.

The nurse is planning care for an 11-year-old admitted for surgical treatment of a fractured femur. The child also has attention-deficit hyperactivity disorder, predominantly inattentive type. What is the priority nursing action? 1. Encourage the child to keep up with school work 2. Give the child a written schedule of daily activities 3. Limit the number of visitors 4. Provide verbal explanations of what to expect during hospitalization

2 Children with attention-deficit hyperactivity disorder (ADHD), predominantly inattentive type, have trouble holding attention on tasks or play activities, experience difficulty organizing tasks and activities, and are easily distracted/side-tracked. They cannot give close attention to detail and dislike and/or avoid tasks that require mental effort over a long period. The key nursing intervention to help the child with ADHD adjust to hospitalization is providing a calm, structured, organized, and consistent environment. A written chart or list of daily activities will help remind the child of what to expect and what will happen at any given time. A structured environment helps these children organize their thoughts and activities. (Option 1) It is important for the child to keep up with school work to the fullest extent possible so the child does not fall behind. Catching up will be more difficult for a child with ADHD than for a child without the diagnosis. A structured environment can help the child plan time for school work. (Option 3) It is important that children with ADHD have visitors as they will likely have impaired social skills and may feel socially isolated. However, the number of visitors may need to be limited to avoid an overly distracting environment. (Option 4) Verbal explanations of what to expect during hospitalization can be provided in a clear, concise manner that allows the child to ask questions. However, because this child will be easily distracted, will not seem to listen when spoken to directly, and is often forgetful, verbal instructions may not be the most effective communication approach. Educational objective: The most important nursing intervention in caring for a child with ADHD is providing a structured, consistent, and organized environment. A written schedule of activities wil

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? 1. Client claims to have more energy and vigor since starting therapy 2. Client has clear future plans involving personal goals and family milestones 3. Client has signed a contract promising not to commit suicide 4. Client reports losing amitriptyline and requests a refill

2 Clients receiving treatment for depression and suicidal ideation must be carefully monitored for indications of increasing intent. During the client interview, the nurse should assess: - Access to psychiatric medications - Availability of help during a crisis (eg, counselor, family) - Future goals and plans - Home and work environment risks - Overall affect and level of energy - Possible access to weapons Clients who articulate long-term personal goals and family milestones are less likely to commit suicide (Option 2). (Option 1) Clients often feel more energetic after beginning treatment, yet thoughts of suicide may not have fully resolved and the client may now have the energy to follow through with suicide plans. (Option 3) "No-harm/no-suicide" contracts are widely used in clinical practice to support a client's ability to avoid acting on suicidal thoughts. This practice is controversial as there is no evidence that contracts reduce suicide rates. These agreements do not guarantee safety and have no legal credibility. (Option 4) Amitriptyline is a tricyclic antidepressant, an overdose of which is extremely dangerous and likely fatal. Although the nurse may interpret the client's report of having lost the prescription as an attempt to be compliant, the nurse must also be aware that the client may be "stockpiling" medication for a suicide attempt. Educational objective: Nursing care for clients with suicidal ideation includes assessment of home and work environments, access to psychiatric medications, overall affect, and energy level. Clients who articulate long-term personal goals are less likely to commit suicide.

A client with obsessive-compulsive disorder (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? 1. Engage other staff members to remove the client from the bathroom 2. Give a reminder that the client has been cleaning the bathroom for 1½ hours and it is time to take a break 3. Tell the client that the bathroom is very clean and that this behavior is unreasonable 4. Tell the roommate to use the shower in another room

2 Clients with OCD engage in rituals and behaviors that help reduce the anxiety or stress rooted in their obsessions (recurrent thoughts, impulses, or images that cause notable distress). If the ritual is interrupted, the client will experience increased anxiety. A client with compulsive behavior often does not realize the amount of time or how many times the same activity has been performed. By providing reflective feedback about the client's behavior, the nurse is acknowledging the behavior in a nonjudgmental manner. The nurse should also help the client become involved in other activities and problem-solving skills. (Option 1) Engaging other staff members to remove the client from the bathroom is confrontational and will increase the client's and roommate's anxiety; this approach is not necessary or therapeutic. (Option 3) Pointing out that the bathroom is clean does not change the client's obsessive thoughts. Saying that the client's behavior is unreasonable conveys a message of disapproval and would increase the client's anxiety. (Option 4) Telling the roommate to use a different bathroom allows the client to continue the ritualistic behavior, is non-therapeutic, reinforces the behavior, and avoids the issue. Educational objective: Clients with OCD engage in rituals and activities that help reduce the anxiety associated with unacceptable thoughts, images, and impulses. Therapeutic approaches to a client with OCD include pointing out the amount of time the client has spent performing an activity and redirecting the client to another activity.

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? 1. "I know how anxious you must be. Watching some television might help you relax." 2. "Tell me more about your thoughts and feelings regarding the situation." 3. "The biopsy result shows that you have cancer, but many cancers are treatable." 4. "Waiting for test results can be stressful. I am sorry I cannot tell you more."

2 Clients with life-limiting diagnoses often experience anxiety, frustration, and the phases of grief. The nurse must assess the client's knowledge and feelings regarding the illness. Use of therapeutic communication (eg, active listening, reflection, focusing) allows the nurse to determine client needs and strengthens the nurse-client relationship, which is instrumental in helping the client cope with difficult information (Option 2). The health care provider (HCP) should inform the client of biopsy results so that the prognosis and plan of treatment can be discussed. Although a cancer diagnosis may be difficult for the client to receive, a complete, factual discussion of the diagnosis can help the client feel more in control. (Option 1) Indicating knowledge of the client's feelings and changing the subject weaken the nurse-client relationship by making the nurse seem uncomfortable with the situation, minimizing the client's feelings, and disregarding client concerns. (Option 3) The HCP should be involved in informing the client about the biopsy results. It is best that both the HCP and nurse be present to address all questions and concerns the client may have. (Option 4) An automatic response is a nontherapeutic communication technique that deflects the client's feelings, thereby weakening the nurse-client relationship. The nurse should encourage the client to share their thoughts. Educational objective: Clients with life-limiting diagnoses experience anxiety, frustration, and grief as they cope. The nurse should use therapeutic communication (eg, active listening, reflection, focusing) to determine the client's understanding and strengthen the nurse-client relationship before discussing difficult news (eg, new cancer diagnosis).

Yesterday, the client was weaned from the mechanical ventilator and an intravenous infusion of lorazepam. The client has been alert and oriented for 24 hours 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? 1. Amnesia 2. Delirium 3. Dementia 4. Psychosis

2 Delirium or acute cognitive dysfunction is a syndrome commonly seen in hospitalized clients; it is reversible but difficult to diagnose. Clients may manifest delirium states that can be hypoactive (eg, quiet, disorientation, change in level of consciousness, memory loss), hyperactive (eg, restlessness, agitation, hallucinations, paranoia), or mixed. Manifestations of delirium develop acutely and are difficult to differentiate from those associated with pain, anxiety, and medications. Early diagnosis and treatment are advantageous as delirium is associated with increased mortality (especially in critically ill clients on mechanical ventilation). Delirium is difficult to assess; it is recommended that nurses use a standardized tool (eg, Confusion Assessment Method for the ICU) or checklist (eg, Intensive Care Delirium Screening) for this purpose. (Option 1) Amnesia affects short- and long-term memory loss. It can be intentionally induced by drug use or may occur as a result of trauma or underlying physical/psychological disease processes. Amnesia is not the most likely condition manifested by this client. (Option 3) In contrast to delirium, dementia is gradual in onset and causes an irreversible and progressive cognitive decline. Remote memory is spared initially and there is no impairment of consciousness until the late stages of the disease. (Option 4) Psychosis does not have an acute onset. Clients with this condition are usually oriented but have auditory (not visual) hallucinations. It is not likely in this client. Educational objective: New-onset confusion regarding sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy can be manifestations of delirium in a critically ill client who was previously alert and oriented.

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? 1. Compensation 2. Displacement 3. Projection 4. Reaction formation

2 Displacement, one of many ego defense mechanisms, occurs when a person shifts uncomfortable feelings or impulses about one situation or person to a substitute situation or person deemed acceptable to receive these uncomfortable feelings or impulses. (Option 1) Compensation involves experiencing a perceived deficit in one area and making up for it by overachieving in another. An example is someone not doing well academically who focuses on doing well in sports. (Option 3) Projection involves feeling uncomfortable with an impulse or feeling and easing the anxiety by assigning it to another person. An example is a husband with thoughts of infidelity who then accuses his wife of being unfaithful. (Option 4) Reaction formation involves transforming an unacceptable feeling or impulse into its opposite. An example is a client with cancer who fears dying but behaves in an overly optimistic and fearless manner about his treatment and prognosis. Educational objective: Displacement is an ego defense mechanism that involves transferring uncomfortable feelings, emotions, or impulses about one person or situation to a substitute person or situation.

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? 1. "Both of you will benefit from supportive counseling." 2. "How are you feeling about your baby?" 3. "I will have the doctor speak to your husband." 4. "Why do you think your husband feels this way?"

2 Learning that their newborn has a genetic disorder (eg, Down syndrome) is an overwhelming experience for most parents. They may initially react with shock, disbelief, and/or denial. Once they accept the diagnosis, parents may be filled with uncertainty and doubt and experience an array of emotions, including guilt, depression, and anger about the presumed loss of their perfect child. When helping the family cope with the crisis, the nurse needs to keep the lines of communication open and offer support. The nurse should use open-ended therapeutic communication techniques that encourage the family members to verbalize what they are feeling or experiencing (Option 2). (Option 1) This is a true statement; supportive counseling is usually beneficial to new parents of children with disabilities. The nurse can refer clients to family support groups or even make the initial phone call for them. However, the nurse should first encourage the parents to express how they are feeling. (Option 3) This is not the best response. The nurse has a role and responsibility to offer support to clients experiencing a crisis. (Option 4) This is accusatory and nontherapeutic. The nurse should avoid asking "why" questions when attempting to gain more information. Educational objective: Parents of newborns diagnosed with Down syndrome or other developmental disabilities may experience shock or disbelief along with a wide array of emotions. Nurses should be supportive by using therapeutic communication techniques that encourage the family to talk about what they are experiencing and/or feeling.

A client is receiving nasogastric tube feedings as nutritional rehabilitation for anorexia nervosa. After a weigh-in, the client learns of gaining 2 lb (0.9 kg) 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? 1. Have the client keep a journal and write about feelings 2. Initiate one-on-one supervision of the client during feedings 3. Remind the client that gaining weight means being able to go home 4. Say that the client is not fat and ugly

2 Nutrition support (enteral tube feedings and total parenteral nutrition) is usually reserved for clients with anorexia nervosa who are severely ill and/or have not responded to oral nutritional therapy. Such clients are at high risk for medical complications from anorexia nervosa, including death. Criteria for nutrition support include: - Severe weight loss that is life threatening - Client's unwillingness to adhere to a treatment plan of oral feedings The priority nursing actions for this high-risk client include interventions to meet physiological and safety needs. Providing one-on-one supervision during the tube feeding will ensure that the client is actually receiving the feeding and prevent the client from stopping the feeding and/or pulling out the nasogastric tube. During the one-on-one contact with the client, the nurse can promote a therapeutic and trusting relationship with the client by: - Being honest and accepting of the client - Presenting the reality of the condition - Acknowledging the client's feelings of loss of control and anger - Encouraging the client to express feelings and fears (Option 1) This is an appropriate intervention for a client with anorexia nervosa. Feelings related to lack of control are an underlying problem for these clients, who use food as a way to deal with them. Keeping a diary or journal of feelings will help the client recognize and express them more clearly. However, this is not the priority nursing action. (Option 3) This may be a true statement; clients with anorexia nervosa are usually discharged to out-patient follow-up and treatment or to a residential treatment facility once an acceptable weight gain has been achieved and maintained. However, this is not the priority nursing action. (Option 4) Clients with anorexia nervosa have a distorted body image and a

The nurse on the mental health unit received report on 4 clients. Which client should the nurse see first? 1. Client diagnosed with major depressive disorder who has consumed no food from the past 3 meal trays 2. Client diagnosed with post-traumatic stress disorder who reports an anxiety level of 8/10 and is pacing in the room 3. Client newly admitted with bipolar mania who reports sleeping only 4 hours last night 4. Client newly admitted with obsessive-compulsive disorder who has spent the last hour counting socks

2 Post-traumatic stress disorder (PTSD) may occur in people who have seen or experienced a terrifying, traumatic event (eg, war, tornado, rape, plane crash). Symptoms of PTSD include re-experiencing the traumatic event via flashbacks, nightmares, and feelings of distress in reaction to reminders; avoiding reminders of the trauma (eg, places, activities, thoughts, other triggers); and increased anxiety and emotional arousal (eg, insomnia, hypervigilance, outbursts of rage, irritability). Clients with an anxiety level of 8/10 and pacing behavior are demonstrating distress and require immediate attention as they might harm themselves or others. (Option 1) Clients with major depressive disorder frequently demonstrate loss of appetite, weight loss, and insomnia (typical depression). Some with atypical depression will experience increased appetite, weight gain, and hypersomnia. This client's lack of appetite needs to be addressed but is not the priority at this time. (Option 3) Clients experiencing acute mania have a decreased need for sleep and boundless energy; they often do not sleep for days. This is an expected behavior in a client newly admitted with a manic episode. As the client's manic episode is resolved via medications and therapy, sleep patterns will improve. (Option 4) Clients with obsessive-compulsive disorder perform compulsive behaviors (rituals) to decrease their level of anxiety. When newly admitted, the client should be given time to perform the rituals to avoid causing panic anxiety. Treatment will focus on assisting the client to develop better coping behaviors and gradually reduce the time spent on the ritualistic behavior. Educational objective: Clients with post-traumatic stress disorder have periods of extreme anxiety and emotional arousal during which they can be a danger to themselves or other

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? 1. A client who experienced a panic attack for the first time in 6 months after a minor car accident yesterday and is requesting a refill for alprazolam 2. A client who is experiencing a fever and diarrhea 2 days after the health care provider increased the sertraline dose 3. A client taking phenelzine who is concerned about food-medication interactions and is requesting a list of foods to avoid 4. A client who has attention-deficit hyperactivity disorder and is experiencing insomnia and irritability 2 days after starting methylphenidate

2 Serotonin can be increased by the addition or high doses of serotonergic medication, or by some herbal medications (eg, St. John's wort), placing clients at risk for serotonin syndrome. Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia). The nurse should call this client back to investigate the symptoms further. (Option 1) Panic attacks can be frightening but typically last less than 10 minutes. A panic attack following a stressful event does not pose an immediate risk; the request for a refill of alprazolam (benzodiazepine for acute anxiety relief) can wait. (Option 3) Phenelzine is a monoamine oxidase inhibitor that has multiple food interactions (eg, foods containing tyramine), which can cause hypertensive crisis. This client needs further education to prevent this condition, but is asymptomatic and not in immediate danger. (Option 4) Stimulants (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are commonly used for attention-deficit hyperactivity disorder (in both children and adults) and are commonly associated with insomnia, irritability, diminished appetite, weight loss, and headaches. Educational objective: Serotonin can be increased by the addition or high doses of serotonergic medication, or by some herbal medications (eg, St. John's wort), placing clients at risk for serotonin syndrome. Management of Care

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? 1. The client and spouse are soon moving into a new neighborhood 2. The client's boss has asked the client to represent the company at an upcoming convention 3. The client's primary health care provider (HCP) of 30 years is retiring and the client will be seeing a new HCP 4. The client's son is getting married in a few months

2 Social anxiety disorder (SAD) is characterized by an excessive and persistent fear of social or performance situations in which the client is exposed to strangers and the possibility of scrutiny by others. Examples of such social interactions include meeting unfamiliar people, being observed eating or drinking in public, and giving a speech. The client may fear criticism, embarrassment, humiliation, and rejection from unfamiliar people in unfamiliar social situations and will exhibit physical symptoms of anxiety such as sweating, trembling, palpitations, diarrhea, and blushing. Although all these situations could provoke some degree of anxiety in a client with SAD, having to represent the company at a convention with hundreds of strangers is most likely what brought this client to the community mental health center. Clients with SAD often have anticipatory anxiety and worry for days or weeks before a feared event. They may recognize that their fear is exaggerated and will seek assistance and counseling. (Option 1) The prospect of a new neighborhood may cause the client some anxiety; however, in this situation, the client has some control over exposure to new neighbors. The client can control this fear by limiting encounters or avoiding the neighbors altogether. (Option 3) Seeing a new HCP may cause some degree of discomfort in a client with SAD; however, as a one-on-one encounter, it is not like to cause severe anxiety or panic. (Option 4) In this situation, the client will be around familiar and possibly unfamiliar people. If necessary, the client can create a comfort zone by limiting contact with unfamiliar people. Educational objective: Clients with social anxiety disorder have an excessive, persistent fear of social or performance situations involving strangers and the possibility of criticism, embarrassmen

The nurse is caring for a client admitted with abdominal pain, who has been diagnosed with somatic symptom disorder after a thorough evaluation finds no medical cause for the symptoms. Which intervention should the nurse include in the plan of care? 1. Advocate for an elimination diet to identify the cause of the symptoms 2. Limit time spent discussing physical symptoms with the client 3. Reinforce negative examination results when pain medication is requested 4. When abdominal pain is mentioned, remind client that it is not real

2 Somatic symptom disorder (SSD) is a psychological disorder that develops from stress, resulting in medically unexplainable physical symptoms (eg, abdominal pain) that disrupt daily life. Clients with SSD focus an excessive amount of time, thought, and energy on the symptoms, often seeking medical care from multiple health care providers. Nursing interventions focus on minimizing indirect benefits and developing client insight. To minimize the indirect benefits from being "sick" (secondary gains), the nurse should: - Redirect somatic complaints to unrelated, neutral topics - Limit time spent discussing physical symptoms (Option 2) To promote insight and healthy coping mechanisms, the nurse should assist the client to: - Identify secondary gains (eg, increased attention, freedom from responsibilities) - Recognize factors that intensify symptoms (eg, increased stress, reminders of a deceased family member) - Incorporate appropriate coping strategies (eg, relaxation training, physical activity) (Option 1) An elimination diet would increase the client's focus on the symptoms and is inappropriate, as physiological causes have already been ruled out. (Option 3) The client's symptoms are real despite the lack of diagnostic findings. The nurse should administer analgesics as prescribed. (Option 4) Disputing the validity of the client's symptoms may increase the client's stress level and exacerbate symptoms. Educational objective: Somatic symptom disorder occurs when stress causes medically unexplainable physical symptoms that disrupt daily life. Nursing interventions include limiting discussion of symptoms and identifying secondary gains, factors that intensify symptoms, and coping strategies.

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? 1. "Don't you know it's not morning yet?" 2. "It's time to get back to bed now." 3. "You might fall if you wander in the dark." 4. "You should not leave your room without assistance."

2 Sundowning refers to the increased confusion experienced by an individual with dementia; it occurs at night, when lighting is inadequate, or when the client is excessively fatigued. Wandering is a common associated behavior. A client with mild-to-moderate dementia may need frequent reality reorientation to promote appropriate behaviors. However, with advanced dementia, reality orientation may not be effective and might cause the client to feel anxious, leading to inappropriate behaviors and aggression. In this situation, validation therapy is more appropriate and involves recognizing and exploring the client's feelings and concerns but not reinforcing or arguing with any incorrect perceptions. (Option 1) This statement calls attention to the client's memory and cognitive issues but does not provide any useful information for reorientation. In addition, this type of statement may reinforce anxieties and fears in a client who is already feeling insecure and scared about the cognitive changes, leading to anger and possible aggression. (Option 3) This option provides little reorientation information. (Option 4) This statement has a paternalistic tone and seems to penalize the client. This type of statement may cause the client to get angry, leading to escalating negative behaviors. Educational objective: Appropriate communication techniques to assist a client with dementia while avoiding anxiety and other negative behaviors include reorientation in the earlier stage of dementia and validation in the later stage of dementia. Psychosocial Integrity

The nurse is caring for a hospitalized elderly client who is admitted with pneumonia. Which assessment finding is most consistent with the diagnosis of delirium? 1. Client is alert but disoriented to time 2. Client is inattentive and hallucinating 3. Client reports decreased enjoyment in previously pleasurable activities 4. Family reports a gradual progressive inability to remember recent events

2 The Confusion Assessment Method (CAM) is used to determine delirium. The signs are acute mental status changes that fluctuate and inattention with disorganized thinking and/or altered level of consciousness. The disorganized thinking includes hallucinations. Risk factors for delirium include older age, prior cognitive impairment, presence of infection, severe illness or multiple comorbidities, dehydration, psychotropic medication use, alcoholism, vision impairment, and pain. Delirium has an abrupt onset and is a symptom of other problems. Up to 60% of hospitalized elderly clients have delirium prior to or during hospitalization, but it is often missed by nursing. (Option 1) This can be due to dementia or just an acute mental status change. Further assessment would be necessary. However, fluctuating mental status changes and inattention that are characteristic of delirium are not present in this client. (Option 3) This is a sign of depression. Two simple screening questions for depression include the following: "During the past month, have you often been bothered by feeling down, depressed, or hopeless?""During the past month, have you often felt minimal interest or pleasure in doing things you used to enjoy?" (Option 4) This describes dementia. Its onset is slow and insidious, and family members usually notice it first. The client's attention level is usually normal. Educational objective: Delirium has a sudden onset and involves fluctuating mental status and inattention with disorganized thinking and/or altered level of consciousness. Dementia has a slow onset, usually with normal attention. Depression involves loss of interest in previously pleasurable activities. Psychosocial Integrity

A client with a 20-year history 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? 1. "How long has the oil been leaking from your head?" 2. "Let's go back to your room and look for your headband together." 3. "There is no oil coming out of your head." 4. "You are going to miss breakfast if you do not go into the dining room."

2 The client, while delusional, is exhibiting signs of anxiety. The priority action for the nurse is to intervene in a manner that will assist in reducing the client's unease. The headband is part of the client's delusional system; it is highly likely that the client will continue to be apprehensive until the headband or substitute is found. Offering to help the client look for the headband conveys a sense of caring and helps establish a trusting relationship. Once the client has calmed down, the nurse will minimize any conversation about the "crack" and the "oil" and can direct the client to reality-oriented activities. Delusions are fixed, false beliefs that are accepted by the client as real and cannot be changed by logic, reason, or persuasion. Categories of delusions include the following: > Persecutory - client thinks others are "out to get me" > Ideas of reference - common events refer specifically to the client > Grandiose - client has the perception of special importance or powers that are not realistic > Somatic - false ideas about bodily functioning Nursing interventions include the following: - Not arguing or challenging the belief - Reinforcing reality by talking about and encouraging the client to participate in real events. The nurse should not delve into or have long conversations about the delusional belief system. (Option 1) This response focuses on the delusional content and is not therapeutic. It does not help alleviate the client's anxiety. (Option 3) Challenging the delusional content is not therapeutic and will not change the client's belief. (Option 4) This statement does not help reduce the client's anxiety. Educational objective: The priority nursing action for a client exhibiting anxiety is to intervene in a manner that helps make the client feel more at ease. Delusions are fixed, fa

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? 1. "Do not let your mother take naps in the afternoon." 2. "Our social worker can discuss long-term care options with you." 3. "We can ask the health care provider for medication that will help your mother sleep." 4. "Your mother can be cared for in a nursing home."

2 This caregiver is experiencing high levels of stress and exhaustion related to caring for the client; without help, the caregiver could easily experience burnout. A social worker can provide information on resources and services for assistance and support; these include adult day programs, in-home assistance, visiting nurse services, and home-delivered meals. The social worker can also provide the names of agencies that seek the support of others in similar situations (eg, local chapter of the Alzheimer's Association). (Option 1) Keeping a client with Alzheimer disease awake during the day is a behavioral strategy that may reduce the risk of sundowning (increased confusion and agitation in the evenings). However, this response does not address the caregiver's stress and exhaustion. (Option 3) Antipsychotic medications are used cautiously in elderly clients with dementia due to the high risk of a cardiovascular event. This response does not provide an effective approach to the caregiver's increasing levels of stress. (Option 4) Institutional care may be the best option for this client. However, giving an opinion or telling the caregiver what the appropriate action "should" be is a non-therapeutic response. Educational objective: Caregivers of clients with Alzheimer disease and other types of dementia often experience burnout due to stress and exhaustion. They need information on community resources that can provide assistance with client care.

A new nurse is caring for an adolescent transgender client. What question would be appropriate when assessing the client's gender identity? 1. "Do you prefer being referred to as 'he' or 'she'?" 2. "How would you describe your gender?" 3. "What gender were you originally?" 4. "What is your preferred name?"

2 Transgender clients may fear judgment or embarrassment and withhold information, avoid seeking treatment, or refuse care as a result. This is often related to past experiences of discrimination or stigma when receiving health care. Therefore, it is important to use therapeutic communication and avoid stereotypes to establish trust. Transgender clients may identify as male or female or as neither or both genders. It is important for the nurse to determine clients' gender identity by asking open-ended questions that allow clients to explain their identities in their own words (Option 2). (Option 1) The client may not identify as simply male or female. Asking closed-ended questions (eg, whether the client prefers "he" or "she") does not allow for client elaboration. (Option 3) Because the client does not identify with the gender designated at birth, referring to a transgender client's "original gender" may cause distress and discomfort. The nurse should instead ask what sex the client was assigned on the original birth certificate. (Option 4) Asking "What is your preferred name?" is not open-ended and does not thoroughly assess gender identity. However, the client's preferred and legal names may be different. The nurse should use the client's preferred name to show respect and to develop a therapeutic relationship. Educational objective: Transgender clients may identify as male or female or as neither or both genders. The nurse should use open-ended questions that allow clients to explain their identities in their own words.

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? Select all that apply. 1. Explore the meaning behind the client's delusions 2. Focus on reality and verbally reinforce it 3. Focus on the client's feelings secondary to the delusions 4. Gently confront the client about the false beliefs 5. Present logical explanations to discredit the delusions

2, 3 Clients with persecutory delusions (paranoid delusions) believe that they are being persecuted or harmed (eg, spied on, cheated, followed, poisoned). Focusing on the client's feelings secondary to the delusion is an example of empathy, one of the most important parts of the therapeutic nurse-client relationship. When nurses attempt to understand clients' feelings and their meaning, clients realize that someone is trying to understand them and the nurse-client relationship grows (Option 3). Focusing on reality and verbally reinforcing it will decrease the time that the client spends thinking about the delusions (Option 2). For example, the nurse may focus on the client's feelings by stating, "I understand that it is frightening to know that someone is trying to poison you." Reality orientation may also be helpful by telling the client, "What you are thinking is part of your disease and not real." (Option 1) Attempting to explore the meaning behind a delusion will encourage the client to focus/think more on this delusion. (Option 4) Confronting the client about the delusion is not therapeutic because arguing will not eradicate the delusion. It also hinders the development of a trusting nurse-client relationship. (Option 5) Clients believe that their delusions are real despite proof otherwise. Presenting logical explanations to discredit the delusions will not help. Educational objective: When communicating with a delusional client, the nurse must focus on the client's feelings and reinforce reality rather than argue or present evidence that the delusion is false or irrational. Psychosocial Integrity

The nurse is admitting a client with malnutrition related to anorexia nervosa. Which of the following actions are appropriate to include in the care of this client? Select all that apply. 1. Allow the client to continue to exercise per usual routine 2. Assist the client in reflecting on triggers of disordered eating 3. Maintain strict record of protein and calorie intake 4. Remain with the client for the duration of each meal 5. Weigh the client each morning prior to any oral intake

2, 3, 4, 5 Anorexia nervosa is a psychogenic eating disorder with potentially fatal physiological implications. Clients commonly become extremely underweight and protein-energy malnourished. Clients admitted for anorexia nervosa are typically in a crisis state, and the priority is restoring physiological integrity through appropriate weight gain and nutritional intake. Nursing care includes: - Assisting the client in reflecting on triggers for dysfunctional eating and fears and feelings related to gaining weight (Option 2) - Maintaining strict documentation of dietary protein and calorie intake to ensure healthy weight gain (Option 3) - Remaining with the client during and 1 hour following meals to ensure intake and prevent purging behaviors (Option 4) - Establishing a weekly weight-gain goal (typically 2-3 lb/wk [0.91-1.36 kg/wk]) - Weighing the client at the same time each morning (after voiding and before any oral intake) and wearing the same clothing to assess efficacy of nutritional support (Option 5) - Limiting physical activity initially and gradually increasing as oral intake improves - Not focusing on food initially, but encouraging participation in meal planning as the client nears target weight (Option 1) Clients admitted with anorexia nervosa should not continue to exercise, because this would cause further energy deficit and worsen malnutrition and end-organ damage (eg, renal failure). Educational objective: Clients admitted with anorexia nervosa must increase caloric intake and stop exercising to promote weight gain. The nurse should record consumed calories, weigh the client daily, remain with the client during and for 1 hour following meals, and encourage discussion about dysfunctional eating triggers. Psychosocial Integrity

The nurse is developing a plan of care for a 16-year-old client with bulimia nervosa. Which interventions would be included in the plan of care? Select all that apply. 1. Allow client to remain on current laxatives 2. Assess client for electrolyte imbalances 3. Be alert to hidden or discarded food wrappers 4. Do not allow client to keep a food diary during hospitalization 5. Monitor client for 1-2 hours after each meal in a central area

2, 3, 5 Bulimia nervosa is an eating disorder common among adolescent girls and characterized by cycles of uncontrollable overeating (binging) followed by compensating behaviors to avoid weight gain (purging). Weight-maintenance behaviors include self-induced vomiting, fasting, laxative abuse, and excessive exercise. Clients may be of normal weight, which contributes to the hidden nature of this disorder. Clients with bulimia often experience extreme guilt associated with their increasing lack of control and attempt to hide evidence of their actions (eg, hidden food wrappers from binging, discarded food from unfinished meals). Clients should be monitored around meal times, and particularly for 1-2 hours after eating to observe for purging. Purging behaviors, particularly vomiting, may result in electrolyte imbalances, such as hypokalemia, that can cause cardiac arrhythmias. (Option 1) Clients with bulimia nervosa often use laxatives inappropriately to rid their bodies of undigested food in an effort to control their weight. Such measures should not continue in the treatment setting. (Option 4) A food diary helps the client and caregivers track the type and amount of food that the client has eaten. It is also an excellent means of helping the client understand the health implications of the disorder. Educational objective: Clients with bulimia nervosa should be monitored for signs of hidden binging or purging activity, particularly for 1-2 hours after meals. Excessive vomiting may result in electrolyte imbalances, including hypokalemia.

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? Select all that apply. 1. "Everything is going to be all right." 2. "Tell me about when you started noticing this behavior." 3. "We have the bleeding under control." 4. "Why didn't you bring your child in sooner?" 5. "You must be very upset after seeing this."

2, 3, 5 Nurses use therapeutic communication to provide support for clients and families and allow them to express thoughts and feelings. Broad openings and relevant questions can help uncover important information that will assist with decision making (Option 2). Therapeutic communication gives relevant information to the parents about the physical condition of the client to help alleviate their anxiety (Option 3). Empathetic statements establish trust and encourage expression of feelings (Option 5). Self-injury (eg, cutting) in adolescence is commonly a coping mechanism used when a client is emotionally overwhelmed. Although not necessarily a suicide attempt, it is a clear indication that this client is unable to process current stressors in life and needs formal assessment by a mental health care provider with experience in adolescent psychiatry. (Option 1) Giving false reassurance (eg, "Everything is going to be alright.") is nontherapeutic communication as it implies that there is no cause for concern and provides no specific information about this client's condition. (Option 4) Asking judgmental questions (eg, "Why didn't you bring your child in sooner?") is nontherapeutic as it may cause the client's parents to be defensive, thereby hampering communication. Educational objective: Providing relevant information, using empathetic statements, communicating with broad openings, and asking relevant questions are forms of therapeutic communication. These methods foster trust, allow expression of feelings, and elicit important information to assist with decision making.

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? Select all that apply. 1. Bradypnea 2. Diaphoresis 3. Hallucinations 4. Lethargy 5. Tachycardia

2, 3, 5 One of every 6 clients undergoing an emergency surgical procedure will show some signs of alcohol withdrawal during the hospital stay. Screening for heavy use of drugs and alcohol should occur at several points during hospitalization to avoid complications of withdrawal. Delirium tremens and other withdrawal symptoms can be prevented with benzodiazepine administration during hospitalization. The stages of alcohol withdrawal do not always occur as a progressive sequence. (Option 1) Decreased respiratory rate is not a sign of alcohol withdrawal. It is more commonly seen in alcohol or opiate overdose. (Option 4) Clients experiencing alcohol withdrawal symptoms will be agitated and have tremors and hyperreflexia. Educational objective: Alcohol dependency is frequently missed during the admission process. Clients should always be screened for heavy use of alcohol or benzodiazepines as withdrawal is potentially life-threatening and avoidable. Signs and symptoms of delirium tremens include agitation, fever, tachycardia, hypertension, and diaphoresis.

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? Select all that apply. 1. Administer a dose of prescribed PRN haloperidol before the client's behavior escalates further 2. Distract and redirect the client by asking for help folding napkins for the following day's meals 3. Inform the client that the health care provider will be notified about the inappropriate behavior 4. Promptly obtain another plate of food and insist that unlicensed assistive personnel feed the client 5. Use direct eye contact and say to the client, "I can see that you are upset; this is a safe place"

2, 5 Clients with Alzheimer disease (AD) often exhibit behavioral problems (eg, agitation, resisting care) due to cognitive decline. Behavioral management techniques include: - Acknowledgement of the client's emotions, which reduces feelings of being isolated and misunderstood (Option 5) - Reassurance that the client will be kept safe from harm - Distraction (eg, photographs, music, television) to divert the client's attention - Redirection to simple tasks (eg, folding towels/napkins, stacking plates) (Option 2) (Option 1) Antipsychotic medications (eg, haloperidol, risperidone, olanzapine) are associated with increased mortality when used for agitation in clients with dementia. These medications should be used after all other measures have failed. (Option 3) Threatening to call the health care provider disrupts the nurse-client relationship and may worsen the client's agitation and behavioral problems. (Option 4) Offering activities that may have precipitated the behavior will likely worsen the agitation. The nurse should assess the client to determine the cause of the agitation (eg, pain, fear, fatigue) and address it. A new meal can be offered after the client is calm. In addition, the nurse should promote autonomy for as long as possible and should not feed clients who are still able to feed themselves (eg, client with moderate AD). Educational objective: Behavioral management for agitated clients with Alzheimer disease includes acknowledging client feelings, reassuring safety, distracting, and redirecting.

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? 1. Impaired social interaction 2. Impaired verbal communication 3. Risk for deficient fluid volume 4. Risk for impaired skin integrity

3 A diagnosis of schizophrenia with catatonia can be made if the clinical features meet the criteria for a diagnosis of schizophrenia and include at least 2 of the following additional features: - Immobility—the client remains in a fixed stupor or position for long periodsRefuses to move about or engage in activities of daily livingMay have brief spurts of excitement or hyperactivity - Remaining mute - Bizarre postures—the client holds the body rigidly in one position - Extreme negativism—the client resists instructions or attempts to be moved - Waxy flexibility—the client's limbs stay in the same position in which they are placed by another person - Staring - Stereotyped movements, prominent mannerisms, or grimacing Clients with catatonic schizophrenia are unable to meet their basic needs for adequate fluid and food intake and are at high risk for dehydration and malnutrition. The priority nursing action is to anticipate the client's needs, and to ensure that the client is well hydrated and has adequate nourishment. Some clients will need total care. (Option 1) Impaired social interaction is also an appropriate nursing diagnosis in a client with catatonic schizophrenia. However, it is not a priority, especially during the early phases of the disease. (Option 2) The client's mutism makes the diagnosis of impaired verbal communication appropriate, and the nurse should gently encourage this client to talk without undue expectations or pressure. This is not the priority nursing diagnosis. (Option 4) If this client is in a bizarre or fixed posture, there may be a risk for decreased circulation and pressure ulcers. The nurse needs to encourage ambulation and/or provide range-of-motion exercises. Educational objective: Clients with catatonic schizophrenia are unable to meet their own needs for fluids, fo

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? 1. Ask the client to make a verbal contract to not harm self 2. Document that the client is not currently suicidal 3. Place the client in an inside hallway with one-on-one observation 4. Return the client to the waiting room with the spouse

3 Any client who cannot definitively say that currently he/she is not suicidal should be considered a "yes" and appropriate protective measures should be instituted to prevent suicidal actions. The client is under the hospital's care and the department must assume responsibility for the client's safety. Placing the client in an inside hallway can prevent the client from running outside. The client needs constant supervision by a hospital employee until a secure room is available. The client should never be left alone without hospital supervision. (Option 1) A verbal contract is a viable option but might not be accomplished appropriately in the triage area. Also, its efficacy is questionable. Emergency department triage should be accomplished in 3-5 minutes. In addition, the triage nurse may not have the skills to adequately perform this intervention. Safety should always be the first priority, and precautions should be taken until the client is determined to not be suicidal. (Option 2) Any ambivalence, especially given the client's previous actions and statements, should be considered a "yes." (Option 4) It is unfair to expect the spouse to perform the same level of care as a health care provider; the spouse brought the client to the hospital for additional help. It would be appropriate to have the spouse present with the client in a secure setting. The spouse would also be instructed to keep the client in sight at all times. Having the client and spouse return to the waiting room would provide the opportunity for the client to bolt from the hospital. Educational objective: Any client who expresses ambivalence about being suicidal should be treated as a "yes." The client must be in a safe environment with hospital supervision and should not be left alone.

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 minutes 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? 1. "I'm sorry. I should have reminded you to sign in." 2. "It is not my fault that you forgot to sign in." 3. "It is your responsibility to sign in when you return from a pass." 4. "You were late coming back from your pass. Is that why you did not sign in?"

3 Clients with antisocial personality disorder often disregard the rules, have a history of irresponsible behavior, and blame others for their behavior. They avoid responsibility for their own behavior and the consequences of their actions using numerous excuses and justifications. Nursing interventions include setting firm limits and making clients with antisocial personality disorder aware of the rules and acceptable behaviors. The nurse should require the client to take responsibility for his/her own behavior and the consequences of not following the rules and regulations of the unit. (Option 1) This is a non-therapeutic response; by apologizing to the client, the nurse is implying that it was the nurse's responsibility to remind the client to sign in. (Option 2) This is a non-therapeutic response as the nurse is on the defensive and not focusing on the client. (Option 4) This is a non-therapeutic response; it is confrontational and assumes the reasoning behind the client's behavior. The response also requires a yes or no answer, which does not facilitate communication. Educational objective: Clients with antisocial personality disorder often disregard the rules, have a history of irresponsible behavior, and blame others for their behavior. Nursing interventions include setting firm limits and making clients aware of the rules and acceptable behaviors. Psychosocial Integrity

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? 1. "I need for you to get rid of these bugs that are crawling under my skin." 2. "Hear that? She told me to kill my father." 3. "That song is a message sent to me in secret code." 4. "Those Martians are trying to poison me with the tap water."

3 Delusions are one of the positive symptoms of schizophrenia. Delusions are false beliefs that have no basis in reality and are unrelated to a client's culture or intelligence. When presented with proof that the delusion is irrational or untrue, the client continues to believe it is real. Clients experiencing delusions of reference will believe that songs, newspaper articles, and other events are personal and significant to them. Other examples of delusions are below: > Grandeur - "I need to get to Washington for my meeting with the president." > Control - "Don't drink the tap water. That's how the government controls us." > Nihilistic - "It doesn't matter if I take my medicine. I'm already dead." > Somatic - "The doctor said I'm fine, but I really have lung cancer." (Option 1) This client statement is an example of a tactile hallucination, which gives the client the sensation of being touched. (Option 2) This client statement is an example of an auditory hallucination, specifically a command hallucination. Clients experiencing auditory hallucinations hear sounds and voices others do not. (Option 4) This client statement is an example of a persecutory (paranoid) delusion. Clients with such delusions believe that they are being threatened or treated unfairly in some way. Educational objective: Delusions are a positive symptom of schizophrenia. Delusions of reference cause clients to feel as if songs, newspaper articles, and other events are personal to them.

The nurse provides teaching for a client newly prescribed disulfiram for alcohol abstinence. Which information is the priority for the nurse to include? 1. Disulfiram is not a cure for alcoholism 2. Importance of continuing to see a therapist 3. List of everyday items containing hidden alcohol 4. Medical alert bracelet should identify disulfiram therapy

3 Disulfiram (Antabuse) is a form of aversion therapy that promotes abstinence from alcohol. If the client consumes alcohol while taking disulfiram, unpleasant side effects (eg, headache, intense nausea/vomiting, flushed skin, sweating, dyspnea, confusion, tachycardia, hypotension) can occur. If large amounts are consumed, the reaction can be fatal. Disulfiram therapy does not cure alcoholism; the client should continue seeing a therapist (Options 1 and 2). Due to the hazards of treatment, clients are carefully selected for disulfiram therapy, and informed consent is often required. It is a priority for the nurse to educate the client about the hazards of drinking alcohol and about sources of hidden alcohol (Option 3). Teaching includes: - Avoid hidden alcohol in: > liquid cold and cough medications > aftershave lotions, colognes, and mouthwashes > foods such as sauces, vinegars, and flavor extracts - Abstain from alcohol for 2 weeks after the last dose as the disulfiram reaction could still occur - Wear a bracelet alerting others of being on disulfiram therapy (Option 4) Educational objective: Disulfiram is a medication that promotes abstinence from alcohol by causing uncomfortable, potentially fatal reactions when alcohol is consumed. Clients must avoid sources of hidden alcohol (eg, liquid cough medicine, aftershave, mouthwash). Effects of the drug can last 2 weeks after the last dose.

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? 1. "I am busy right now but can stay for a few minutes." 2. "I can call the clergy to come sit with you." 3. "I can stay and sit with you if you would like." 4. "I don't think I should interrupt your family time."

3 During the end-of-life process the client's family members may be frightened, sad, confused, or concerned, and may ask staff questions about belief systems or the death process. Sometimes clients or family members simply want the nurse to sit with them and provide reassurance that their loved ones are worthy of time and attention. The most therapeutic response by the nurse is to sit with the client and/or family for at least a few minutes. (Option 1) Telling family members that a nurse is busy is not a helpful response. They may feel guilty about asking for the nurse's time and attention. If needed, the nurse can ask coworkers to help with other assigned clients. (Option 2) Although calling clergy members may be appropriate, it may take several hours for them to arrive. This is not the most helpful response. (Option 4) Family members who ask the nurse to stay for a few minutes may have questions or need emotional support. In such cases, it is not helpful for the nurse to decline. Educational objective: During the end-of-life process, the client and family members typically go through several emotional stages, each requiring therapeutic communication techniques by the nurse. The nurse can help the client and family by providing a few minutes of time and attention. The nurse should validate the family's needs by providing emotional support. Psychosocial Integrity

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? 1. "I find it helpful to investigate the options. I will get you a pamphlet about hospice services." 2. "It's hard to say what the best decision is, but I know hospice provides wonderful care." 3. "These decisions are challenging. Tell me your spouse's beliefs about end-of-life." 4. "You seem overwhelmed. I'll contact a chaplain to come and talk with you about the options."

3 End-of-life decisions (eg, hospice, code status) often overwhelm clients and medical decision-makers due to the magnitude of the choices and feelings of guilt that may accompany decisions. Clients and their families may lean on hospital staff to guide these decisions. These moral and ethical dilemmas require the nurse to have strong therapeutic communication skills. When discussing decisions related to client care, the nurse should facilitate exploration of the client's emotions, values, and beliefs, rather than offer personal opinions. Nurses can promote self-exploration by using open-ended questions and guiding phrases (Option 3). (Option 1) Providing information is an appropriate response when that is what the client is seeking. However, there is no indication that the spouse seeking advice requires additional information, and this response does not promote further communication. (Option 2) The nurse's opinion and personal biases can influence clients/family members and may even push them toward decisions incongruent with their values and beliefs. Giving advice is not therapeutic and does not promote open communication. (Option 4) It is within the nurse's scope to discuss moral and ethical decisions with clients. Deferring these conversations to another professional (eg, chaplain) instead of talking with the individual inhibits the therapeutic relationship and does not support client self-exploration. Educational objective: When discussing ethical decisions related to client care, it is important for the nurse to use open-ended questions and guiding phrases to facilitate exploration of clients'/family members' emotions, values, and beliefs regarding the topic. Nurses should avoid giving advice and influencing individuals' decisions.

After a client with Alzheimer disease is found wandering in the middle of the street at 3:00 AM 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? 1. Ensure that the client is never left alone 2. Notify neighbors of the client's tendency to wander 3. Place a chain lock on the door above or below the client's eye level 4. Place a safe return bracelet on the client's non-dominant hand

3 Individuals with dementia may wander and become lost during any stage of the disease. The most effective strategy to prevent wandering is to make modifications to secure the environment. These include: - Placing locks above or below eye level on doors that lead to the outside. Clients with Alzheimer disease (AD) lose their peripheral vision; they cannot see objects unless they are directly in front of them or they purposely move their heads (Option 3). - Adding a motion sensor or alarm that goes off when someone tries to exit - Placing a large stop sign on door exits - Disguising a door with a curtain or wall hanging - Using childproof doorknob covers - Placing a black mat or black strip by an exit. The client may perceive this as an impassable black hole due to changes in depth perception. (Option 1) Clients with AD should not be left alone; however, it is impossible for any caregiver to watch another person every minute of the day. Clients with AD can walk out of their homes while family members are sleeping. (Option 2) Notifying neighbors can be helpful if the client leaves the residence but will not prevent wandering. (Option 4) Safe return or identification bracelets are important, but they will not prevent wandering. A bracelet should be placed on the dominant hand to minimize the chance of removal. Educational objective: The most effective strategy to prevent clients with dementia from wandering is to make modifications to secure their environment. These include installing locks above or below eye level on doors, hiding exits with wall hangings or curtains, placing a black mat in front of exits, and using doorknob covers, motion detectors, and alarms.

Which statement by a client with a diagnosis of dependent personality disorder would the nurse recognize as progress toward a positive therapeutic outcome? 1. "I really appreciate all the time you have spent trying to help me." 2. "I think I really messed up at work today." 3. "My mother could not drive me here today, so I took the bus." 4. "When my parents go away on vacation, I'm planning to stay with my cousin."

3 Individuals with dependent personality disorder have a persistent and extreme need to be taken care of that manifests as submissive and clinging behaviors and fear of separation. Additional characteristics of dependent personality disorder may include: - Difficulty in making day-to-day decisions - An excessive need for advice, reassurance, and nurturance from others - Lack of self-confidence - afraid to do things on one's own - Afraid of confrontation or expressing disagreement with others - Feelings of helplessness and anxiety when alone; fear of being unable to take care of oneself A client making a decision about and carrying out a daily activity on his/her own would be indicative of progress toward a therapeutic outcome. (Option 1) Clients with dependent personality disorder will often express appreciation or make flattering comments to the nurse/therapist to gain approval. (Option 2) Clients with dependent personality disorder lack confidence in their own abilities; this client is expressing self-doubt and is not showing evidence of improvement. (Option 4) The need to stay with someone while the client's parents are away is not evidence of progress toward a therapeutic outcome; the client cannot tolerate being alone. Educational objective: Clients with dependent personality disorder have an extreme need to be taken care of by another person, cannot make decisions on their own, and have intense fear of separation and being left alone. The ability to make a decision and act on one's own would indicate progress toward a therapeutic outcome.

A client with a history of obsessive-compulsive personality disorder (OCPD) is seeking treatment for a gastrointestinal disorder and is scheduled for a colonoscopy at 10:00 AM. Due to a computer glitch, the procedure is postponed to 3:00 PM. Which response would be characteristic of an individual with OCPD? 1. "How dare they change my appointment? I insist that the procedure be done at 10:00 AM." 2. "That's fine. I can come in whenever it is convenient for everyone." 3. "This is unacceptable. I had my whole day planned out." 4. "Why are they doing this to me?"

3 Individuals with obsessive-compulsive personality disorder are typically self-willed and obstinate, punctual, pay attention to rules and regulations, and need to control both internal and external experiences. These traits are very extreme and result in rigidity and inflexibility. In this scenario, a change has been made in the client's schedule for the day and is outside of the client's control. This could cause significant distress and impaired functioning so that the client feels emotionally paralyzed. (Option 1) This response is characteristic of a client with narcissistic personality disorder, who may behave in grandiose, demanding, and entitled ways and needs to have his/her own way. (Option 2) This response could be attributed to a client with dependent personality disorder, who tends to be passive and submissive and wants to please others. (Option 4) This response would be more characteristic of an individual with paranoid personality disorder, who may feel slighted or is overly sensitive. Educational objective: An individual with obsessive-compulsive personality disorder is typically rigid and inflexible and has a need to control both internal and external experiences. A change in a schedule that is outside of the client's control could cause significant distress.

The nurse is caring for a client who entered the psychiatric emergency department 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? 1. "I know it must be terrible to see your son like this, but he will be fine." 2. "Most people have permanent side effects after an episode like this." 3. "Your son will have to remain here for observation until we know more." 4. "Your son would be fine right now if he had not taken these drugs."

3 It is important to distinguish clinically between the very similar presentations of intoxication, delirium secondary to a medical condition, dementia, and psychiatric disorders involving distorted perceptions of reality in order to begin the appropriate treatment. Some illicit substances (eg, marijuana, LSD, PCP) have been reported to cause episodes of severe, acute psychosis. Some clients will never experience another episode of psychosis. However, in rare cases, illicit substances may trigger a genetic predisposition to development of a mental illness. There is no way to establish the long-term prognosis. (Option 1) The long-term prognosis after an episode of psychosis is impossible to predict with any accuracy. It is tempting to offer comfort to a client's family in a time of crisis, but the nurse should never make promises. (Option 2) Most cases of drug-induced psychosis are transient. (Option 4) After substance abuse has been verified, client education regarding drug abuse and therapy or counseling are indicated. However, it is extremely unprofessional to judge clients for their behavior and lifestyle choices. Educational objective: Clients demonstrating altered mental status should be assessed for intoxication and medical causes of delirium (electrolyte/glucose imbalances, pneumonia, sepsis, malnutrition) prior to involving a mental health care professional.

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? 1. Daily sleep disturbance or significant weight loss 2. Decreased ability to think or low energy 3. Depressed mood or loss of interest or pleasure 4. Thoughts of worthlessness or recurrent thoughts of death

3 Major depressive disorder (also known as unipolar depression) is a subtype of depressive disorder, classified by specific symptoms that interfere with the ability to perform activities of daily living, work, sleep, and enjoy activities that are usually pleasurable to the client. For the diagnosis to be made, 5 or more of the following symptoms must be present almost every day for at least 2 weeks, and 1 of the symptoms must be depressed mood or loss of interest or pleasure. (Option 1) Daily sleep disturbance or significant weight loss is a symptom of depressive disorders; these are not key clinical features necessary for diagnosis. (Option 2) Decreased ability to think or low energy is a symptom of depressive disorders; these are not key clinical features necessary for diagnosis. (Option 4) Thoughts of worthlessness or recurrent thoughts of death are symptoms of depressive disorders; these are not key clinical features necessary for diagnosis. Educational objective: The 2 key clinical features of major depressive disorder (unipolar depression) are depressed mood and loss of interest or pleasure. One of these symptoms must be present daily for at least 2 weeks for the diagnosis of major depressive disorder to be made.

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? 1. "Cancer is no longer a death sentence; you may live for many years." 2. "I will ask the chaplain to talk to you sometime today." 3. "People with cancer experience fear of dying; tell me about your concerns." 4. "Tell me about your life and hopes for the future."

3 Many individuals diagnosed with cancer experience anxiety and fear related to death and desire to talk with someone about these feelings. To promote a therapeutic relationship, the nurse should initiate conversations by acknowledging clients' fears, use open-ended statements to invite them to talk about death, and actively listen as they verbalize their feelings. (Option 1) The nurse offers false reassurance by making this statement. Providing false reassurance is not part of a therapeutic relationship or an effective communication strategy. (Option 2) This statement does not acknowledge the client's concerns and blocks communication. The nurse should first assess the client's cultural and spiritual practices. If the client requests spiritual support, then the nurse may make a referral to the chaplain's office. (Option 4) By changing the subject, the nurse is attempting to redirect the conversation away from the client's desire to talk about death; this does not promote a therapeutic relationship. Educational objective: Fear of dying is a common concern for many clients with a terminal disease. The nurse should acknowledge these feelings and use open-ended statements and active listening to invite clients to talk about death.

A female client who was the victim of acquaintance rape 2 months ago is receiving therapy for posttraumatic stress disorder (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? 1. "It may take time to overcome those thoughts and feelings." 2. "Those kinds of thoughts are self-destructive. You should stop thinking about it." 3. "You could not have anticipated the rape. You did not deserve or ask for it." 4. "You have to stop blaming yourself so you can move on with your life."

3 One of the common features of PTSD is a persistent distorted perception about the cause of the traumatic event that leads the affected individuals to blame themselves or others. Clients may be in a persistent, negative emotional state of guilt and/or shame and also believe that they are responsible for what happened. This is particularly true in cases of rape. A pervasive culture of "blaming the rape victim" also contributes to clients' perception that the rape was somehow their own fault. Providing a realistic perspective of the rape may help clients develop a more objective view of their perceived role in the traumatic event and may reduce feelings of self-blame and guilt. The nurse needs to reinforce repeatedly that rape is never the victim's fault (Option 3). (Option 1) This is a nontherapeutic response as it reinforces the client's feelings of self-blame and guilt. The best therapeutic response should reinforce that the client is not to blame for the rape. (Option 2) This is a nontherapeutic response; it does not assist in changing the client's perception of the traumatic event and implies that the client should not cope with the experience at all. (Option 4) This is a nontherapeutic response. Clients cannot simply make negative feelings disappear; these need to be resolved through therapy. Educational objective: Clients who suffer from PTSD often experience feelings of guilt and shame; they believe that they are responsible for what happened and that, somehow, they could have prevented the traumatic event. Using therapeutic communication, the nurse needs to convey that what happened was not their fault. Psychosocial Integrity

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? 1. "Finding support with other local grieving parents can be helpful." 2. "Self care is important at this time. Take a break while the staff completes care." 3. "Some parents like to cuddle and speak to the child. Take the time you need." 4. "This must be a very difficult time. How have you dealt with loss in the past?"

3 Postmortem care of a child is a highly stressful and emotional time for family and staff members. After death, the psychosocial care of the family and the bond between parent and child should be facilitated through specific interventions intended to assist parents through the grieving process. Parents should be allowed as much time as they need with the child's body and should not be rushed while they say goodbye. The nurse should be present to provide emotional support and identify if parents wish to help participate in some or all care activities, such as bathing and dressing the child. Parents should be allowed time to cuddle with and speak, read, or sing to the child, as well as perform special activities associated with cultural beliefs (Option 3). (Options 1 and 4) Providing community resources for grief support groups and assessing parents' coping mechanisms are important interventions; however, this is not a priority immediately following the death of a child. (Option 2) Self care is important during the grieving process; however, parents should first be provided the opportunity to be involved in the postmortem care of their child. Educational objective: Nurses should provide emotional support and facilitate the parent-child bond in the immediate moments following the death of a child. Participation in postmortem care promotes the psychosocial wellness of the family.

A client with severe major depressive disorder is lying in bed and has not moved for 3 hours. The client will respond slowly to "yes" and "no" questions; otherwise, the client does not respond when spoken to. The clinical manifestations exhibited by the client are known as: 1. Psychogenic dystonia 2. Psychogenic gait 3. Psychomotor retardation 4. Somatization

3 Psychomotor retardation is a clinical symptom of major depressive disorder. Manifestations of psychomotor retardation include slowed speech, decreased movement, and impaired cognitive function. The individual may not have the energy or ability to perform activities of daily living or to interact with others. Psychomotor retardation may range from severe (total immobility and speechlessness -catatonia) or mild (slowing of speech and behavior). Specific clinical findings of psychomotor retardation include the following: - Movement impairment - body immobility, slumping posture, slowed movement, delay in motor activity, slow gait - Lack of facial expression - Downcast gaze - Speech impairment - reduced voice volume, slurring of speech, delayed verbal responses, short responses - Social interaction - reduced or non-interaction Clients with major depressive disorder may also show symptoms of psychomotor agitation, characterized by increased body movement, pacing, hand wringing, muscle tension, and erratic eye movement. (Option 1) Psychogenic dystonia is a psychogenic movement disorder characterized by involuntary muscle contractions that cause slow, repetitive movements such as twisting and abnormal postures. (Option 2) Psychogenic gait is a psychogenic movement disorder characterized by unusual standing postures and walking. The client may experience knee buckling and falling or may veer from side to side as if staggering. (Option 4) Somatization is a term to describe physical symptoms that cannot be explained by a medical condition or disease. Educational objective: Psychomotor retardation is a clinical finding in some clients diagnosed with major depressive disorder. The key features include decreased movement, inability or decreased ability to talk, and impaired cognitive function. Psychosocial Integrity

The nurse is managing the care of a client diagnosed with chronic anxiety. Which behavior demonstrates to the nurse that the client possesses resilience? 1. Avoids anxiety-producing situations 2. Is able to identify anxiety-inducing triggers 3. Practices stress reduction techniques daily 4. Relies on anxiolytic medication to manage symptoms

3 Resilient people readily deal with the stress they face by using interventions such as deep breathing, meditation, thought interruption, and muscle relaxation. (Option 1) Stress and the anxiety it can cause are unavoidable; taking steps to manage the physical and emotional responses to stress encourages and supports an individual's resilience. (Option 2) Identifying one's anxiety triggers is helpful, but the individual must take action to deal with both the origin and response to the stress. (Option 4) Although anxiolytic therapy may be necessary to manage anxiety, resilience centers on the adaptive techniques an individual uses to address the resulting symptoms. Educational objective: Resilience plays a primary role in an individual's ability to prevent and recover from mental illness and to manage daily stressors. Resilience is strengthened by the practice of appropriate coping skills.

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? 1. Allow the child to stay home when the child seems particularly anxious 2. Encourage the parent/caregiver to sit in the classroom with the child 3. Insist on school attendance immediately, starting with a few hours a day 4. Return the child to school when the cause of the school phobia has been identified

3 School phobia (also known as school refusal or school avoidance) is a childhood anxiety disorder in which the child experiences an irrational and persistent fear of going to school. Having the child return to school immediately is the best approach for resolving school phobia and is associated with a faster recovery. If necessary, gradual exposure to the school environment can be implemented; the child can attend school for a few hours and then gradually increase the time to a full day. A gradual approach may decrease the child's sensitization to the classroom. If the child is allowed to remain out of school, the problem will only worsen, with potential deterioration of academic performance and social relationships. (Option 1) Allowing the child to stay home will only reinforce the acting-out behaviors associated with refusal to attend school. The parent/caregiver needs to support the child and talk about the cause of the anxiety, but the child needs to go to school. (Option 2) Having the parent/caregiver stay in the classroom with the child is not a permanent solution to relieving the child's anxiety and is not recommended. (Option 4) Determining the cause of the school phobia is important in helping to alleviate the child's symptoms and in coping with the return to school. However, returning the child to the classroom immediately is the most important action. Educational objective: A child with school phobia needs to return to the classroom immediately. Insisting on school attendance, along with other supportive interventions, will help the child make a faster adjustment. Psychosocial Integrity

The registered nurse is counseling the parent of a child recently diagnosed with attention-deficit hyperactivity disorder (ADHD), combined type. Which statement by the parent requires an intervention? 1. "I should offer a choice between 2 things for my child's clothes or meals." 2. "I will need to advocate for an individualized educational plan for my child." 3. "My child will outgrow this disorder around age 20." 4. "When talking with my child, I should not be multi-tasking."

3 Symptoms of ADHD usually continue into adulthood; current research indicates that children do not outgrow the condition. However, individuals with ADHD learn to cope with and manage the symptoms and achieve their full potential, leading healthy and satisfying lives. They may move into a condition of being "recovered," but this is usually a dynamic and ongoing state. (Option 1) Children with ADHD are usually overwhelmed and overstimulated when faced with numerous choices. Offering 2 choices will help organize and structure the child's decision-making process. (Option 2) There are legal mandates requiring school-based services and accommodations for children with ADHD. However, some teachers and/or school systems may not be as familiar with these requirements; it is important that parents of children with ADHD advocate for these individualized services. (Option 4) Parents and caregivers should make direct eye contact and focus on their children when giving instructions. Other distractions should be minimized to avoid overstimulation. Educational objective: Two common misunderstandings about ADHD are that children outgrow it as they become adults, and that dietary modifications (eg, restricting additives and/or sugar) will improve or "cure" the symptoms. Neither statement is true. These individuals learn to cope with and manage their symptoms as they grow older, but they do not outgrow ADHD.

The nurse is providing care to a client experiencing posttraumatic stress disorder following a terrorist attack at the client's place of worship. What is the priority nursing action? 1. Acknowledge the client's feelings of anger 2. Assess the client's support system 3. Encourage the client to talk about the trauma 4. Offer the client a PRN sleep medication

3 The first step toward resolution of posttraumatic stress disorder (PTSD) is the client's readiness (ability and willingness) to discuss the details of the traumatic event without experiencing high levels of anxiety. The nurse must assess clients with PTSD for their readiness to talk about the experience and encourage them to discuss the trauma at their own pace. The nurse should also use active listening as a therapeutic approach to build trust and allow clients to vent. This will assist in decreasing their feelings of isolation. The nurse can also guide the client in identifying event details that are most troubling and trigger a sense of loss of control. The effectiveness of the client's coping mechanisms can be identified, and alternate strategies to replace maladaptive ones can be explored. (Option 1) It is important to acknowledge any feelings that the client may have about the trauma; the priority nursing action is to encourage the client to talk about the event. (Option 2) Assessing the client's support system is an appropriate nursing intervention; however, it is not the priority. (Option 4) Sleep aids are used for clients with PTSD and insomnia; however, this is only a temporary solution to one aspect of PTSD clinical presentation. Educational objective: The nurse should encourage clients with posttraumatic stress disorder to talk about the experience at their own pace, listen actively to build trust, and allow clients to vent. This will assist in decreasing their feelings of isolation.

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? 1. Call social services to assist the client in community resources for domestic violence victims 2. Clean the facial laceration and prepare to assist the health care provider with suture placement 3. Have the spouse leave the room so that the client can be spoken with and examined in private 4. Place the arm in a shoulder sling for immobilization and prepare for an immediate x-ray

3 The priority for possible domestic abuse victims is to remove them from any sources of immediate danger, including suspected abusers. Such clients should be questioned and assessed alone so that the suspected abusers do not guide their answers or intimidate them from providing truthful responses. In this case, the spouse appears angry and should, as a priority, be removed from the room to prevent further potential harm to the client or staff (Option 3). (Option 1) Notifying social services of suspected abuse should occur with the client's permission after any immediate threats are removed and after physiological needs are met. This should not be done in the presence of any potential abusers. (Option 2) Cleaning the laceration and preparing for sutures are appropriate interventions but are done after a suspected abuser is removed. The nurse also follows facility guidelines for documenting, gathering evidence, and/or photographing injuries before cleaning and further treatment. (Option 4) The arm should be x-rayed to assess for fractures and may require a sling for immobilization, but potential sources of harm are removed from the room first. Educational objective: If a client shows possible signs of abuse or neglect, the priority is to remove any sources of immediate danger (eg, suspected abuser) from the room to prevent further harm. Assessments and further interventions can occur after ensuring the client's safety.

An 87-year-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? 1. Encouraging frequent fluid intake 2. Keeping the bed elevated with the side rails raised 3. Providing one-on-one supervision 4. Turning lights off in client's room to reduce stimulation

3 This client is experiencing impairment in cognitive and psychomotor functioning and most likely has delirium brought on by the urinary tract infection. This is not an uncommon occurrence in elderly clients. The client's most immediate needs are safety and prevention of physical injury. Initially, the client should be placed in a room near the nurses' station with one-on-one supervision and frequent reorientation to time, place, and situation. As the condition improves, the client will continue to require frequent observation. (Option 1) It is important for this client to be well hydrated; this can best be accomplished through IV fluids and electrolyte replacement but not by encouraging the client to increase fluid intake. (Option 2) Clients who are agitated often try to get out of bed, even if it means climbing over the side rails. Keeping the bed elevated and side rails raised increases the risk of a fall or other injury as the client attempts to leave the bed. (Option 4) A dark room could worsen the client's confusion, agitation, and disorientation. Lighting helps maintain orientation to the environment; the client's room should be well lit during the day, and dim nightlights should be used at night. Educational objective: Safety is a high priority for clients with delirium. Disorientation, confusion, agitation, and difficulty interpreting reality all increase the risk for physical injury. Close observation, including one-on-one supervision, is essential to ensure client safety. Psychosocial Integrity

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? 1. "Do you have any relatives or close friends who can help you through this?" 2. "Has your spouse seemed depressed lately?" 3. "This has been very overwhelming for you. What are you feeling right now?" 4. "Well, you did find your spouse. You need to focus on helping your spouse get better."

3 This client's spouse has experienced a traumatic or crisis event (also referred to as "a critical incident"). When faced with a traumatic situation, clients are often overwhelmed and respond with a wide range of emotions and thoughts, including shock, denial, anger, helplessness, numbness, disbelief, and confusion. Clients may also experience physical symptoms, such as hyperventilation, abdominal pain, and dizziness. Priority nursing actions need to be directed at the here and now, providing therapeutic interventions aimed at alleviating the immediate emotional impact of this disruptive crisis event. Acknowledging the severity of the event validates and normalizes the spouse's reaction. Assisting the spouse in identifying feelings and giving the spouse opportunity to ventilate will help reduce immediate emotional stress. (Option 1) Assessing this family's support system is important. However, it is not the priority action at this time. (Option 2) This statement does not address what this client's spouse is experiencing at the moment. At a later time, the nurse can explore the client's history and any events that may have lead to this situation. (Option 4) This response does not address the spouse's concerns. Also, the wording is judgmental and nontherapeutic. Educational objective: Initial reactions to a crisis event may include shock, disbelief, denial, helplessness, and confusion. Nursing actions are directed at providing support to the client. Acknowledging the impact of the event and encouraging the client to ventilate are therapeutic interventions.

The clinic nurse speaks with the spouse of a client being treated for alcohol use disorder. Which statements by the spouse indicate codependence? Select all that apply. 1. "I am focusing on my new hobby and my friends in the book club." 2. "I left and didn't awaken my spouse, who went back to sleep after turning off the alarm clock." 3. "I try to get up early and keep the children from being too loud in the mornings." 4. "If I didn't get so stressed about my job, my spouse wouldn't drink so much." 5. "When my spouse was sick, I called and rescheduled clients so my spouse could rest."

3, 4, 5 Codependent behaviors are those that allow the codependent person to maintain control by fulfilling the needs of the addict first. Behaviors such as keeping the addiction secret, suffering physical or psychological abuse from the addict, not allowing the addict to suffer the consequences of actions, and making excuses for the addict's habit are hallmarks of codependency. If the addict isn't happy, the codependent person will try to make the addict happy. Codependent persons will focus all their attention on others at the expense of their own sense of self. Codependent spouses, friends, and family members keep the client from focusing on treatment; this behavior is counterproductive to both themselves and the client. (Option 1) This statement does not represent codependency but rather indicates that the spouse is focusing on the spouse's own growth and needs rather than the needs of others. (Option 2) This statement does not represent codependency; it indicates that the spouse is allowing the client to suffer the consequence of actions. Educational objective: Codependent spouses, friends, and family members can impede treatment progress of clients with substance use disorders. Codependent behaviors include making excuses for a client's drug/alcohol use, putting a client's needs before one's own, and not allowing a client to suffer the consequences of actions.

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? Select all that apply. 1. "Intimate partner violence is most common in low-income families." 2. "Intimate partner violence is rare in same-sex partnerships." 3. "The abusive partner often demonstrates jealousy and possessiveness." 4. "Victims may not leave due to financial concerns or fear of harm by the abuser." 5. "Violence against a female often intensifies during pregnancy."

3, 4, 5 Intimate partner violence (IPV) is physically, emotionally, verbally, sexually, or economically abusive behavior inflicted by one partner against another in an intimate relationship, to maintain power and control. Nurses must be aware of the risk factors and signs of IPV to recognize victims of abuse and to intervene (eg, separating the victim from the abuser during the health history interview, providing information about community resources). Features of IPV include: - The abusive partner exhibits intense jealousy and possessiveness (Option 3). - The victim of IPV chooses to stay in the relationship for a variety of reasons (eg, fear for life, financial or child custody concerns, religious beliefs) (Option 4). - The abuse begins or intensifies during pregnancy (Option 5). (Options 1 and 2) IPV occurs in all religious, socioeconomic, racial, and educational groups, and in both heterosexual and same-sex partnerships. Educational objective: Intimate partner violence (IPV) is abusive behavior inflicted by one partner against the other in an intimate relationship. IPV occurs in all religious, socioeconomic, racial, and educational groups, and in both heterosexual and same-sex partnerships. IPV often begins or intensifies during pregnancy. Victims often stay in the relationship due to fear, financial or child custody concerns, or religious beliefs, among other reasons.

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? 1. Assess for signs of alcohol withdrawal 2. Assess the need for alcohol rehabilitation referral 3. Let the client sleep off the alcohol intoxication 4. Monitor blood glucose levels during the night

4 Alcohol is a toxin that causes central nervous system depression. Acute alcohol intoxication can cause confusion, coordination impairment, drowsiness, slurred speech, mood swings, and uninhibited actions. Alcohol can also cause hypoglycemia, especially in clients with diabetes mellitus. Although the client is intoxicated, it is difficult to determine if the confusion is caused by alcohol or hypoglycemia or both. The priority is to monitor blood glucose during the night to watch for hypoglycemia, which would require immediate intervention. (Option 1) Alcohol withdrawal generally starts within 8 hours after the last drink and peaks at 24-72 hours. (Option 2) Alcohol rehabilitation referral can be addressed when the client is sober and is not a priority. (Option 3) The client should be allowed to sleep, but monitoring glucose levels is the priority. Educational objective: Alcohol can cause hypoglycemia, but intoxication can make it difficult to differentiate between the effects of alcohol and hypoglycemia. Clients with acute alcohol intoxication, especially those who have diabetes mellitus, should have their blood glucose levels monitored.

A young client is diagnosed with major depressive disorder. Three weeks prior, the client's fiancé 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 fiancé 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? 1. "How could your fiancé be wonderful after saying those things to you?" 2. "I think you are better off without your fiancé." 3. "Maybe the breakup was for the best." 4. "Tell me how you felt when your fiancé broke up with you."

4 Clients with major depressive disorder experience feelings of worthlessness, low self-esteem, hopelessness, and guilt. Anger is turned inward and they may misinterpret reality and have an idealistic perception of a lost entity. They may blame themselves for what has happened, such as losing a loved one or being fired from a job. The nurse needs to remain nonjudgmental, listen to the client attentively, and convey a caring and accepting attitude to promote trust. Allowing the client to identify and verbalize feelings, including anger, in a comfortable environment will help the client see the situation in a more realistic way and come to terms with what has happened. (Option 1) The nurse is challenging the client's perception of reality; this will increase the client's anxiety and inhibit further communication. (Option 2) The nurse is offering an opinion and challenging the client's statement; this is not a therapeutic response. (Option 3) The nurse is offering an opinion; it is not a therapeutic response. Educational objective: Nursing interventions for a depressed client who expresses feelings of worthlessness and guilt and has a distorted sense of reality include listening attentively, encouraging the client to verbalize feelings about what has happened, and helping the client view the situation in a more realistic way.

The nurse is caring for a client with a history of heroin abuse. Which clinical finding may indicate withdrawal? 1. Constipation 2. Constricted pupils 3. Drowsiness 4. Tachycardia

4 Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids are abruptly stopped, dosage is reduced, or a reversal agent (ie, naloxone [Narcan]) is administered. Withdrawal symptoms (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous system activity as the depressant effect of the opioid wanes (Option 4). Although opioid withdrawal is seldom life-threatening, clients who demonstrate signs of acute withdrawal may be given medications, such as methadone, to alleviate discomfort. The nurse should alert the health care provider of suspected withdrawal to facilitate appropriate opioid weaning or maintenance interventions. (Options 1, 2, and 3) Opioid use typically causes constipation, constricted pupils, and drowsiness due to its central nervous system depressant effects. Educational objective: Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids are abruptly stopped or dosage is reduced. Symptoms of opioid withdrawal (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous system activity.

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? 1. Ask where the client is going 2. Immediately follow the client out the door 3. In a loud voice, direct the client to come back to the room 4. Remain silent and allow the client to leave

4 Clients with schizophrenia often become anxious when around other individuals and will seek to be alone to relieve anxiety. Impaired social and interpersonal functioning (eg, social withdrawal, poor social interaction skills) are common negative symptoms of schizophrenia. These are more difficult to treat than the positive symptoms (eg, hallucinations, delusions) and contribute to a poor quality of life. Nursing interventions directed at improving the social interaction skills of a client with schizophrenia include the following: - Making brief, frequent contacts - Accepting the client unconditionally by minimizing expectations and demands - Assessing the client's readiness for longer contacts with the nurse and/or other staff and clients - Being with or close by the client during group activities - Offering positive reinforcement when the client interacts with others (Option 1) Asking where this client is going is nontherapeutic as it requires an explanation of the client's actions. (Option 2) Following this client out the door could increase the client's anxiety. (Option 3) Directing this client to come back to the room is placing a demand that may be unrealistic and does not help develop a sense of trust. Educational objective: Social isolation and impaired social interaction are common negative symptoms of schizophrenia. The client will seek to be alone to relieve anxiety associated with being around others. The nurse needs to be accepting of the client's behavior and continue attempts at brief contact until the client is comfortable.

A client with a history 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 electroconvulsive therapy (ECT) as the initial treatment, the client's spouse says to the nurse, "I can't allow such a cruel treatment. Why can't they just give my spouse medication?" Which is the best response by the nurse? 1. "ECT is safe and your spouse will not feel anything." 2. "It could take up to 3 weeks for medication to become effective." 3. "Your spouse could die by not receiving this treatment." 4. "Your spouse is very ill and ECT might be the best treatment at this time. What are your concerns about ECT?"

4 Due to the severity of this client's clinical presentation, ECT would be the appropriate initial treatment. The client's depression has psychotic features and the suicide attempt used a highly lethal method. The client continues to be highly suicidal as evidenced by behavior and thought content. ECT can be highly effective in helping severe depression, when clients pose a severe threat to themselves and it is not safe to wait until medications take effect. ECT is also used in clients who have not responded to medication or cannot tolerate side effects. During ECT, the client is treated with pulses of electrical energy through electrodes applied to the scalp; the electrical stimulus is sufficient to cause a brief convulsion. General anesthesia and a skeletal muscle relaxant are administered to minimize the motor seizure and prevent musculoskeletal injury. The client feels nothing from the procedure, but confusion and memory loss are common side effects. The usual course of acute therapy is 6-12 ECT treatments performed 2-3 times a week. Response to ECT can be dramatic and life-saving. Maintenance therapy (treatment at 1- to 8-week intervals) can continue on a long-term basis to help prevent relapses. Medication therapy is often given in combination with ECT and is associated with improved outcomes. The best response to a client or family member who expresses doubts about ECT is to ask about their concerns. Responses such as, "Tell me about your concerns," or "What do you understand about ECT?" allow the nurse to assess their knowledge and implement educational interventions to address any misinformation or knowledge gaps. (Option 1) This response does not address the spouse's concerns. (Option 2) Although this statement may be true, it does not address the spouse's concerns. It is not the best response. (Option

The nurse cares for a client who has a do-not-resuscitate prescription, and notes extensive skin mottling and vital signs 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? 1. "Tell me about your favorite anniversary memory that you shared." 2. "That would be very special, but please understand that it may not happen." 3. "We never know; death happens in its own time despite what we may want." 4. "Your spouse's body is shutting down and the time is near; I will stay here with you."

4 End-of-life care includes providing psychosocial support to the client's family members and assisting them through the dying process. This is accomplished by providing factual, open, and honest communication while conveying empathy. The nurse can reduce family members' fear and anxiety by helping them anticipate what to expect as death becomes imminent, while using the therapeutic communication technique of offering self (Option 4). (Option 1) Encouraging the client's spouse to recall fond memories is comforting and therapeutic but does not provide information about the client's imminent death. (Option 2) Telling the client's spouse that the client may not be present for an upcoming event does not convey empathy or provide factual information about the client's impending death. (Option 3) Statements such as "death happens in its own time" are cliché; providing platitudes or trite statements is not therapeutic. Educational objective: When assisting a client's family through the dying process, the nurse should provide factual, open, and honest communication; help the family anticipate what is happening and when death is imminent; and use the therapeutic technique of offering self. Psychosocial Integrity

A nurse performs the initial assessments for 4 assigned clients. The nurse identifies which client as being at greatest risk for the development of delirium? 1. 32-year-old client with gastroenteritis 2. 55-year-old client with coronary artery disease, 4 days post coronary bypass surgery 3. 60-year-old client with type II diabetes, 2 months post bilateral above-knee amputations 4. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis

4 Major predisposing factors for the development of delirium in hospitalized clients include: 1. Advanced age 2. Underlying neurodegenerative disease (stroke, dementia) 3. Polypharmacy 4. Coexisting medical conditions (eg, infection) 5. Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia) 6. Metabolic and electrolyte disturbances 7. Impaired mobility - early ambulation prevents delirium 8. Surgery (postoperative setting) 9. Untreated pain and inadequate analgesia Client 4 has 4 predisposing risk factors: advanced age, acidosis and hypoxemia associated with chronic respiratory failure, and sepsis. This client is at greatest risk for developing delirium. (Option 1) Although gastroenteritis with possible dehydration and electrolyte imbalances predisposes to delirium, this client is not at greatest risk. (Option 2) Although surgery, especially that requiring cardiac bypass, predisposes to delirium, this client is not at greatest risk. Early ambulation and adequate pain control prevent the development of delirium in the postoperative setting. (Option 3) Although coexisting medical conditions, such as diabetes mellitus and impaired mobility, predispose to delirium, this client is not at greatest risk. Educational objective: Risk factors for hospital-induced delirium include advanced age, underlying neurodegenerative disease, infections, medical illness, surgery, impaired mobility, and inadequate pain control.

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? 1. "The gift shop is not even open right now." 2. "I guess the day shift staff needs to be reminded of the rules." 3. "What do you want to get from the gift shop?" 4. "You do not have privileges for leaving the unit. I cannot give you a pass."

4 Manipulative behaviors, such as attempts at staff splitting, are common in clients with borderline and antisocial personality disorders, substance abuse problems, somatic symptom disorder, and bipolar disorder (during the manic phase). The manipulative behavior is aimed at gaining control/power over a person/situation or for material gratification. Clients manipulate by flattery or by pitting staff members against each other. They may "tell" on a staff member or act in a way to give the impression of sincerity and caring. Nursing interventions for manipulative behaviors include: - Setting limits that are realistic, nonpunitive, and enforceable - Using a nonthreatening, matter-of-fact tone when discussing limits and consequences of unacceptable behaviors - Enforcing all unit, hospital, or center rules (Option 4) - Ensuring consistency from all staff members in enforcing set limits (Option 1) Telling the client the gift shop is closed does not address the client's manipulative behavior. (Option 2) Believing the client's statement is not appropriate as it will only reinforce the client's manipulative behavior. (Option 3) Asking the client the reason for going to the gift shop ignores the fact that the client is trying to break the rules. Educational objective: Clients who want to gain power or control over a situation or desire material gratification may use manipulative behaviors (eg, staff splitting). Nursing interventions include setting behavioral limits; using a neutral, matter-of-fact tone when discussing rules and consequences of unacceptable behavior; and ensuring consistency from staff members in enforcing limits. Psychosocial Integrity

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 health care provider (HCP). What is the priority nursing diagnosis (ND) at this time? 1. Hopelessness 2. Ineffective coping 3. Risk for infection 4. Risk for suicide

4 Suicide is the second leading cause of death in people age 15-24. The risk for suicide is increased in individuals with psychiatric disorders, such as depression, and in those who have attempted suicide within the past 2 years. Based on the client's history and statements, the HCP must perform a suicide assessment and take action (ie, psychiatry referral) to provide for the client's safety. This is imperative as the client is prescribed the antidepressant fluoxetine (Prozac) and has had no follow-up with the prescribing HCP. Risk for suicide related to depression is the priority ND. (Option 1) Hopelessness is the belief that a situation or problem is intolerable, inescapable, or unending, and the individual is unable to find a solution. Hopelessness related to inability to find a job, social isolation, lack of medical insurance, and feeling at the "end of my rope" is an appropriate ND for this client, but it is not the priority ND at this time. (Option 2) Ineffective coping is the inability to manage stressors and problems effectively. Depression can affect a client's cognitive ability (eg, poor concentration, lack of judgment) and ability to cope with feelings of despair. Ineffective coping related to inadequate support network, limited socioeconomic resources, and impaired cognitive ability is an appropriate ND for this client, but it is not the priority ND at this time. (Option 3) Risk for infection related to inadequate primary defenses secondary to impaired skin integrity is an appropriate ND for this client, but it is not the priority ND at this time. Educational objective: Risk for suicide related to depression is a priority ND for a client with previous suicide attempts. Psychosocial Integrity

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? 1. "At the moment, I would worry more about how your sibling is doing." 2. "The odds are about 50-50 that you will come down with the disease as well." 3. "Would you like to talk to a health care provider about this?" 4. "You are at risk for the disease. However, there are other factors that contribute to the development of schizophrenia."

4 The best response should acknowledge the reality of the sibling's concern, provide information, and open the door to further discussion about the development of the disease. Research studies indicate that identical twins have about a 50% chance of developing schizophrenia if one twin develops the disease. This points to a genetic component, but schizophrenia is not entirely a genetic disease. The exact cause is unknown; it most likely results from the interaction and combination of a number of different risk factors. Theories about the cause of schizophrenia include the following: > Biochemical theories - abnormalities affecting the neurotransmitters dopamine, serotonin, norepinephrine, and glutamate > Structural brain abnormalities - reduced size of certain brain areas > Developmental factors - prenatal factors such as faulty neuronal connections > Miscellaneous factors - birth trauma, epilepsy, maternal influenza during pregnancy (Option 1) This response ignores the sibling's concerns and is judgmental. (Option 2) This statement presents the facts in a blunt, non-therapeutic manner; it does not facilitate further discussion about the factors contributing to schizophrenia and/or the sibling's feelings. (Option 3) This dismisses the sibling's concerns and is basically a "non-action" on the part of the nurse Educational objective: Information regarding the potential for development of a serious illness, such as schizophrenia, needs to be provided to clients in a realistic manner that allows for discussion and exploration of the client's feelings. The exact cause of schizophrenia is unknown and is probably a combination of genetic, biochemical, structural, and developmental factors.

The student nurse is performing an assessment of a 10-year-old diagnosed with attention-deficit hyperactivity disorder (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? 1. Confusion and a learning disability 2. Delayed physical and emotional development 3. Disorientation and cognitive impairment 4. Low self-esteem and impaired social skills

4 The core symptoms of ADHD include hyperactivity, impulsiveness, and inattention. Hyperactive children are restless; have difficulty remaining seated when required; and exhibit excessive talking, blurting out answers prematurely, and interrupting others. Inattention is characterized by reduced ability to focus and attention to detail, easy distractibility, and failure to follow through (eg, homework, chores). The primary symptoms of ADHD have a negative impact and can make life difficult for children in school, at work, and in social situations. Symptoms interfere with opportunities to acquire social skills and may also result in rejection and critical judgment by peers. The negative consequences of ADHD include: - Poor self-esteem - Increased risk for depression and anxiety - Increased risk for substance abuse - Academic or work failure - Trouble interacting with peers and adults (Option 1) Children with ADHD are more likely to have a learning disability. Confusion is not a typical clinical finding. (Option 2) Although children with ADHD may appear to be emotionally immature for their age, ADHD is not associated with delayed physical growth. (Option 3) Children with ADHD are not disoriented. ADHD is associated with a range of cognitive impairments, but no single cognitive dysfunction typifies all children with the disorder. Some children have no impairment at all. Educational objective: The diagnosis of ADHD includes the presence of hyperactivity, impulsiveness, and inattention. The negative consequences of the core manifestations include impaired social skills, poor self-esteem, academic or work failure, increased risk for depression and anxiety, and increased risk for substance abuse. Psychosocial Integrity

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? 1. The nurse has encouraged exploration of the client's situation 2. The nurse has shown interest in the client's concerns 3. The response conveys empathy toward the client and promotes self-confidence 4. The response devalues the client's feelings and gives false reassurance

4 The nurse has used a nontherapeutic communication technique known as "giving reassurance" or "giving false reassurance." A nurse who does not acknowledge a client's feelings and gives the impression that there is nothing to worry about has devalued the client's concerns. This technique serves to block a therapeutic conversation as the client may feel that the verbalization of additional concerns or feelings will also be devalued. (Option 1) The nurse has not encouraged exploration of this client's feelings and options. This could have been done by using any one of several therapeutic communication techniques (eg, reflecting, focusing, exploring). An appropriate response by the nurse, such as stating, "Tell me what concerns you have," would have facilitated communication with the client. (Option 2) The nurse has shown no interest in the client's concerns; instead, the nurse should show interest, be available, and have a conversation with the client (eg, "I will stay and listen to your concerns"). (Option 3) The nurse has not conveyed empathy (attempting to understand and share the feelings behind a client's actions and words). An empathetic nurse might say, "This must be hard for you," or, "I understand you are upset." Educational objective: The nurse must learn to use effective therapeutic communication skills to enhance the development of a trusting and therapeutic nurse-client relationship. Psychosocial Integrity

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? 1. "Do you need something to help you calm down?" 2. "Don't pay any attention to the voices. Let's go into the dayroom." 3. "The voices are not real. Tell them to go away." 4. "What are the voices saying to you?"

4 The priority nursing action is to explore the content of the hallucinations. This client may be experiencing command auditory hallucinations that could lead to self-directed or other-directed injury and harm. After the content of the hallucinations has been explored, implementing an intervention may be necessary to reduce the potential for violence. Hallucinations are false sensory perceptions that have no external stimuli. They can occur in any of the 5 senses. Auditory hallucinations are the most common, followed by visual, tactile (touch), olfactory (smell), and gustatory (taste). Additional ways to deal with hallucinations include the following: - Telling the client that you know they are real to the client but that you do not hear the voices (or see the vision, feel the sensation) - Not arguing with or challenging the client about the hallucinations - Directing the client to a reality-oriented topic of conversation or activity (Option 1) An antianxiety medication may be needed if the voices are causing this client to become increasingly distressed. Assessment is needed before choosing this option. (Option 2) This choice dismisses this client's concerns about the nature of the voices. (Option 3) Telling the voices to "go away" (voice dismissal) is a technique that some clients find effective in management of hallucinations. It is not the priority nursing action in this client. Educational objective: It is important for the nurse to initially explore the content of a client's hallucinations to assess the risk for harm and/or injury and determine appropriate interventions. The nurse can tell the client that the nurse knows the voices are real to the client but are not heard by the nurse. The client with hallucinations should be directed to reality-oriented activities rather than to further discussion of t

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 gown ties. The client was stabilized and transferred to the psychiatric unit. Which of the following is the highest priority nursing action for this client? 1. Assess the client's risk for another suicide attempt 2. Encourage the client to express current feelings about the medical diagnosis 3. Place the client in a private room near the nurses' station 4. Provide continuous one-to-one observation with the client

4 This client has made a suicide attempt and is at high risk for additional suicidal behavior. Therefore, the client's priority need is for safety. The best nursing action is to provide one-on-one contact with the client to ensure constant observation and that the client does not engage in self-harm. The presence of the nurse will also convey a sense of acceptance, concern, and caring and provide an opportunity for the client to express feelings about the current situation. Additional nursing interventions for the client at high risk for suicide include the following: - Removing sharp and other potentially harmful objects (eg, belts, metal eating utensils, ties, glass items) from the client's environment - Making sure the client swallows medications - Supervising the client during meals - Placing the client in a semiprivate room near the nurses' station (to reduce social isolation and allow easier access to the client) - Making rounds at irregular intervals for the client who does not need constant observation, as well as at shift changes and when staff is unusually busy - Encouraging the client to express feelings, especially anger - Having an open and honest conversation with the client about changing suicide risk (Option 1) This is an appropriate nursing action but not the highest priority action. (Option 2) This is an appropriate nursing action but not the priority action. (Option 3) A client at risk for suicide should be placed in a semiprivate room. Educational objective: The priority nursing action for a client who has made a recent suicide attempt is to ensure the client's safety. The best approach is to provide one-on-one contact and constant observation.

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? 1. Encourage the client to perform deep breathing exercises 2. Explore possible reasons for the episode 3. Place the client in a private room and tell the client to relax 4. Remain in the room with the client

4 This client is experiencing the symptoms of a panic attack and should not be left alone. The priority nursing action is to stay with the client to ensure the client's safety and offer support. Additional nursing actions while the client is experiencing panic symptoms include: - Maintaining a calm, matter-of-fact approach - Speaking calmly and using simple, clear words and phrases when providing information on emergency department procedures - Placing the client in a room with as few stimuli as possible - Administering an anti-anxiety medication such as a benzodiazepine (per health care provider prescription) - Having the client take slow, deep breaths if hyperventilation is a problem (Option 1) Deep breathing exercises can relieve hyperventilation, but the priority is to remain with the client to ensure safety. (Option 2) Discussing the reasons for the panic attack is not appropriate while the client is still symptomatic. Once the client has calmed down, the nurse can discuss reasons for the attacks, evaluate stressors in the client's life, and assist the client in developing prevention strategies. (Option 3) A private room is appropriate; however, just telling a client to relax is not helpful. Educational objective: The priority nursing action for the client experiencing symptoms of a panic attack is for the nurse to stay with the client in a calm environment, ensure the client's safety, and offer support.

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? Select all that apply. 1. "A friend of mine passed away recently. I know how hard losses can be." 2. "I see that you're upset. I will step out while you process these feelings." 3. "It may take a while, but coming to terms with loss gets easier with time." 4. "This is a difficult time. Tell me about how you have been coping." 5. "What are your thoughts about attending a grief support group?"

4, 5 The practices, needs, and experiences of grief vary greatly among individuals. Nurses caring for grieving clients must skillfully use therapeutic communication techniques to strengthen the nurse-client relationship and support clients in exploring emotions and experiences. Reflection (eg, acknowledging client statements) and using open-ended questions or statements assist the client in exploring emotions and allow for expression of needs (Option 4). Nurses may also suggest strategies and share resources (eg, support group) to facilitate the client's grieving process (Option 5). (Option 1) Presuming to understand another individual's grief based on personal experience is not a therapeutic communication technique as it diminishes the experiences and emotions of the client. (Option 2) Clients expressing strong emotions may need time to collect themselves before continuing a discussion. However, leaving the room when a client's emotions are heightened may imply that the client's expression is inappropriate or unacceptable. The nurse should remain with the client and may use therapeutic silence or touch to show support. (Option 3) Automatic or cliché responses (eg, it takes time to deal with losses) are nontherapeutic as they limit discussion and expression of the client's experience and emotion. Educational objective: Nurses should use therapeutic communication techniques (eg, reflecting, asking open-ended questions, suggesting strategies or resources) to support clients' psychosocial needs and build the nurse-client relationship. Minimization, automatic responses, and leaving clients who are sharing strong emotions are nontherapeutic actions.

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? Select all that apply. 1. "How long have your parents been doing things to you?" 2. "Tell me about what happened. I promise not to tell anyone." 3. "This is terrible. Whoever did this to you will be sorry." 4. "What happened is not your fault. You are not to blame." 5. "You did the right thing by telling me. You are not in trouble."

4, 5 When speaking with a child about abuse, the nurse should be direct and honest. The nurse should allow the child to disclose the abuse at a comfortable pace, rather than probe for additional information. The nurse should use open-ended questions and avoid leading questions and statements. Guidelines for the interview: - Speak with the child in private - Be honest about reporting requirements - Use language appropriate to the child's age - Avoid making assumptions or communicating anger, shock, or disapproval - Reassure the child about not being at fault or in trouble (Options 4 and 5) (Option 1) The nurse should not make assumptions about who abused the child. This could lead to bias or false accusations and/or cause the child to fear revealing the identity of the abuser. (Option 2) "Tell me about what happened" is a correct, open-ended question; however, the nurse is required to report abuse and should communicate this requirement to the child. (Option 3) The nurse should avoid making derogatory statements about the abuser, as this can cause the child feelings of embarrassment or fear and end the conversation. Educational objective: When interviewing a child about abuse, the nurse should affirm that the child is not at fault or in trouble and avoid making assumptions or communicating anger, shock, or disapproval. The nurse should be direct and honest about the requirement to report abuse.

A client presents to the emergency department with alcohol intoxication. Assessment shows nystagmus, ataxia, and confusion. The client's breath smells of alcohol. Which prescription from the health care provider should the nurse implement first? 1. Blood draw for liver function tests 2. D5 1/2 normal saline 3. Folic acid, IV 4. Thiamine, IV

Clients with alcoholism can have hypoglycemia. They can also have thiamine (vitamin B1) deficiency related to poor nutrient intake (a healthy diet contains enough thiamine) and alcohol-induced suppression of thiamine absorption. Thiamine deficiency can result in Wernicke encephalopathy (WE). Untreated WE can lead to death or neurologic morbidity (Korsakoff psychosis). In the setting of alcoholism, administered glucose is oxidized by using all the existing thiamine in the body; this can worsen thiamine deficiency, which in turn can precipitate the development of WE in a previously unaffected individual. Because the signs of alcohol intoxication and WE are similar, all intoxicated clients should be given IV thiamine before or with IV glucose (Options 2 and 4). (Option 1) A blood draw for liver functions tests to rule out alcoholic hepatitis is important but not a priority. (Option 3) Clients with alcoholism usually have additional nutritional deficiencies (eg, folic acid, magnesium). Magnesium and multiple vitamins should also be given to these clients. However, thiamine is the essential vitamin to administer before or with IV glucose in a client with suspected alcoholism. Educational objective: IV thiamine is given before or with IV glucose to a client with alcohol intoxication to prevent Wernicke encephalopathy. Clients with alcoholism often have thiamine deficiency.