N161 Midterm

Which symptoms should the nurse recognize that differentiate a client diagnosed with obsessive-compulsive disorder (OCD) from a client diagnosed with obsessive-compulsive personality disorder? 1. Clients diagnosed with OCD experience both obsessions and compulsions, and clients diagnosed with obsessive-compulsive personality disorder do not. 2. Clients diagnosed with obsessive-compulsive personality disorder experience both obsessions and compulsions, and clients diagnosed with OCD do not. 3. Clients diagnosed with obsessive-compulsive personality disorder experience only obsessions, and clients diagnosed with OCD experience only compulsions. 4. Clients diagnosed with OCD experience only obsessions, and clients diagnosed with obsessive-compulsive personality disorder experience only compulsions.

ANS: 1 A client diagnosed with OCD experiences both obsessions and compulsions. Clients with obsessive-compulsive personality disorder exhibit a pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control, but do not experience obsessions and compulsions.

A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Which potentially fatal side effect will the nurse teach the client about? 1. Agranulocytosis 2. Akathisia 3. Dystonia 4. Akinesia

ANS: 1 Agranulocytosis is a potentially fatal disorder in which the client's white blood cell count drops to extremely low levels, placing the client at great risk for infections.

A client diagnosed with AD has been assigned the nursing diagnosis of anxiety R/T divorce. Which correctly written outcome addresses this client's problem? 1. Rates anxiety as 4 out of 10 by discharge 2. States anxiety level has decreased by day one 3. Accomplishes activities of daily living independently 4. Demonstrates ability for adequate social functioning by day three

ANS: 1 An outcome statement must be client-centered, specific, measurable, and contain a time frame, so that it can be evaluated effectively.

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

ANS: 1 Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. In the growth stage, the individual feels a sense of optimism and hope of a rewarding future. Skills that have been nurtured in the previous stages are applied with confidence, and the individual strives for higher levels of well-being.

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

ANS: 1 Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 1: Moratorium.

In the treatment of anxiety disorders, benzodiazepines (such as Ativan and Xanax) are indicated for_________ use and have__________ abuse potential. 1. short-term; high 2. long-term; high 3. short-term; low 4. long-term; low

ANS: 1 Because tolerance to these medications occurs, there is high risk for abuse. Therefore, they should be used as a short-term intervention for anxiety.

A psychiatrist prescribes a MAOI for a client. When teaching the client about the effects of tyramine, which foods will the nurse caution the client to avoid? 1. Pepperoni pizza and red wine 2. Bagels with cream cheese and tea 3. Apple pie and coffee 4. Potato chips and Diet Coke

ANS: 1 Both these foods are high in tyramine.

A nurse is assessing a client diagnosed with fetishistic disorder. What would differentiate this paraphilic disorder from frotteuristic disorder? 1. To derive sexual excitement, fetishistic disorder involves the use of nonliving objects, whereas frotteuristic disorder involves touching and rubbing against nonconsenting people. 2. To derive sexual excitement, frotteuristic disorder involves the use of nonliving objects, whereas fetishistic disorder involves touching and rubbing against nonconsenting people. 3. Clients diagnosed with frotteuristic disorder are heterosexual cross-dressing males, whereas clients diagnosed with fetishistic disorder are homosexual cross-dressing males. 4. Clients diagnosed with fetishistic disorder are heterosexual cross-dressing males, whereas clients diagnosed with frotteuristic disorder are homosexual cross-dressing males.

ANS: 1 Fetishistic disorder involves recurrent and intense sexual arousal from the use of either nonliving objects or specific nongenital body part(s).

A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin Decanoate) from a home-health nurse. The client refuses medication at one regularly scheduled home visit. Which nursing intervention is ethically appropriate? 1. Allow the client to decline the medication and document the decision. 2. Tell the client that if the medication is refused, hospitalization will occur. 3. Arrange with a relative to add the medication to the client's morning orange juice. 4. Call for help to hold the client down while the injection is administered.

ANS: 1 It is ethically appropriate for the nurse to allow the client to decline the medication and provide accurate documentation. The client's right to refuse treatment should be upheld, unless the refusal puts the client or others in harm's way.

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

ANS: 1 It is important to prioritize client interventions that assess the symptoms of COPD prior to any other nursing intervention. Physical needs must be prioritized according to Maslow's hierarchy of needs. This client's problems with oxygenation will take priority over assessing for current suicidal ideations as they can lead to death more quickly if not reversed.

Which factors differentiate the diagnosis of PTSD from the diagnosis of adjustment disorder (AD)? 1. PTSD results from exposure to an extreme traumatic event, whereas AD results from exposure to "normal" daily events. 2. AD results from exposure to an extreme traumatic event, whereas PTSD results from exposure to "normal" daily events. 3. Depressive symptoms occur in PTSD and not in AD. 4. Depressive symptoms occur in AD and not in PTSD.

ANS: 1 PTSD results from exposure to an extreme traumatic event, whereas AD results from exposure to "normal" daily events, such as divorce, failure, or rejection.

A nurse recognizes which treatment as most commonly used for AD and its appropriate rationale? 1. Psychotherapy; to examine the stressor and confront unresolved issues 2. Fluoxetine (Prozac); to stabilize mood and resolve symptoms 3. Eye movement desensitization therapy; to reprocess traumatic events 4. Lorazepam (Ativan); a first-line treatment to address symptoms of anxiety

ANS: 1 Psychotherapy is the most common treatment used for AD.

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

ANS: 1 SAMHSA lists the following as guiding principles for the recovery model: Recovery emerges from hope.

A client with depression and substance abuse has an interrupted sleep pattern. She demands that her psychiatrist prescribe her a sedative. What teaching would the nurse provide about the rationale for the use of nonpharmacological interventions instead? 1. "Sedative-hypnotics are potentially addictive and gradually lose their effectiveness as one builds up tolerance to them." 2. "Sedative-hypnotics work best in combination with other techniques." 3. "Sedative-hypnotics are not permitted for use in patients with substance abuse disorders." 4. "Sedative-hypnotics are not as effective as the antidepressant medications for treating sleep disturbances."

ANS: 1 Sedative-hypnotics are potentially addictive and should be used with caution by clients with a history of substance abuse. Tolerance can easily develop.

By which biological mechanism does EMDR achieve its therapeutic effect? 1. EMDR achieves its therapeutic effect, but the exact biological mechanism is unknown. 2. EMDR achieves its therapeutic effect by causing a decrease in imagery vividness. 3. EMDR achieves its therapeutic effect by causing an increase in memory access. 4.EMDR achieves its therapeutic effect by decreasing trauma associated anxiety.

ANS: 1 Some studies have indicated that eye movements cause a decrease in imagery vividness and distress, as well as an increase in memory access. EMDR is thought to relieve anxiety associated with the traumatic event. However, the exact biological mechanisms by which EMDR achieves its therapeutic effects are unknown.

A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions? 1. "I will need scheduled blood work in order to monitor for toxic levels of this drug." 2. "I won't stop taking this medication abruptly because there could be serious complications." 3. "I will not drink alcohol while taking this medication." 4. "I won't take extra doses of this drug because I can become addicted."

ANS: 1 The client indicates a need for additional information about taking benzodiazepines when stating the need for blood work to monitor for toxic levels. This intervention is used when taking lithium (Eskalith) for the treatment of bipolar disorder.

Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurse's coworker observes this action but does nothing for fear of retaliation. What is the ethical interpretation of the coworker's lack of involvement? 1. Taking no action is still considered an unethical action by the coworker. 2. Taking no action releases the coworker from ethical responsibility. 3. Taking no action is advised when potential adverse consequences are foreseen. 4. Taking no action is acceptable, because the coworker is only a bystander.

ANS: 1 The coworker's lack of involvement can be interpreted as an unethical action. The coworker is experiencing an ethical dilemma in which a decision needs to be made between two unfavorable alternatives. The coworker has a responsibility to report any observed unethical actions.

A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations? 1. The nurse refuses to give any information to the caller, citing rules of confidentiality. 2. The nurse hangs up on the caller. 3. The nurse confirms that the person has been at the facility but adds no additional information. 4. The nurse suggests that the caller speak to the client's therapist.

ANS: 1 The most appropriate action by the nurse is to refuse to give any information to the caller.

A client diagnosed with panic disorder states, "When an attack happens, I feel like I am going to die." Which is the most appropriate nursing response? 1. "I know it's frightening, but try to remind yourself that this will only last a short time." 2. "Death from a panic attack happens so infrequently that there is no need to worry." 3. "Most people who experience panic attacks have feelings of impending doom." 4. "Tell me why you think you are going to die every time you have a panic attack."

ANS: 1 The most appropriate nursing response to the client's concerns is to empathize with the client and provide encouragement that panic attacks only last a short period. Panic attacks usually last minutes but can, rarely, last hours.

What is the most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client? 1. Clarify personal attitudes, values, and beliefs. 2. Obtain thorough assessment data. 3. Determine the client's length of stay. 4. Establish personal goals for the interaction.

ANS: 1 The most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client is to clarify personal attitudes, values, and beliefs. Understanding one's own attitudes, values, and beliefs is called self-awareness.

Which therapeutic communication technique is being used in the following nurse-client interaction? Client: "My father spanked me often." Nurse: "Your father was a harsh disciplinarian." 1. Restatement 2. Offering general leads 3. Focusing 4. Accepting

ANS: 1 The nurse is using the therapeutic communication technique of restatement. Restatement involves repeating the main idea of what the client has said. It allows the client to know whether the statement has been understood and provides an opportunity to continue.

Which client action should a nurse expect during the working phase of the nurse-client relationship? 1. The client gains insight and incorporates alternative behaviors. 2. The client establishes rapport with the nurse and mutually develops treatment goals. 3. The client explores feelings related to reentering the community. 4. The client explores personal strengths and weaknesses that impact behavioral choices.

ANS: 1 The nurse should expect that the client will gain insight and incorporate alternative behaviors during the working phase of the nurse-client relationship.

A newly married woman comes to a gynecology clinic reporting anorexia, insomnia, and extreme pain during intercourse that has affected her intimate relationship. What initial intervention should the nurse expect a physician to implement? 1. A thorough physical, including gynecological examination 2. Referral to a sex therapist 3. Assessment of sexual history and previous satisfaction with sexual relationships 4. Referral to the recreational therapist for relaxation therapy

ANS: 1 The nurse should expect the physician to implement a thorough physical, including a gynecological examination to assess for any physiological causes of the client's symptoms. If no pathology exists, the client may be diagnosed with genito-pelvic pain/penetration disorder. In this disorder, the individual experiences considerable difficulty with vaginal intercourse and attempts at penetration. Pain is felt in the vagina, around the vaginal entrance and clitoris, or deep in the pelvis. There is fear and anxiety associated with anticipation of pain or vaginal penetration. A tensing and tightening of the pelvic floor muscles occurs during attempted vaginal penetration.

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

ANS: 1 The nurse should explain that a chemical imbalance of the brain leads to altered perceptions.

A nurse is instructing a client diagnosed with female sexual interest/arousal disorder. Which symptom and treatment of this disorder should the nurse describe to the client? 1. Avoidance of all genital sexual contact treated by sensate focus exercises 2. Avoidance of all genital sexual contact treated by medicating with tadalafil (Cialis) 3. Anorgasmia treated by vardenafil (Levitra) 4. Anorgasmia treated by systematic desensitization

ANS: 1 The nurse should explain to the client that female sexual interest/arousal disorder is characterized by a reduced or absent frequency or intensity of interest or pleasure in sexual activity. Sensate focus exercises are highly structured touching activities designed to help overcome performance anxiety and increase comfort with physical intimacy.

A newly admitted client asks, "Why do we need a unit schedule? I'm not going to these groups. I'm here to get some rest." Which is the most appropriate nursing response? 1. "The purpose of group therapy is to learn and practice new coping skills." 2. "Group therapy is mandatory. All clients must attend." 3. "Group therapy is optional. You can go if you find the topic helpful and interesting." 4. "Group therapy is an economical way of providing therapy to many clients concurrently."

ANS: 1 The nurse should explain to the client that the purpose of group therapy is to learn and practice new coping skills.

After threatening to jump off of a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first? 1. "Are you currently thinking about harming yourself?" 2. "Why do you want to harm yourself?" 3. "Have you thought about the consequences of your actions?" 4. "Who is your emergency contact person?"

ANS: 1 The nurse should first assess the client for current harmful or suicidal thoughts to minimize risk of harm to the client and provide appropriate interventions. A suicidal client is experiencing a psychiatric emergency. The crisis team's priority is to assess client safety.

In the course of an assessment interview, a female client reveals a history of bisexual orientation. Which action should the nurse initially implement when working with this client? 1. Self-assess personal attitudes toward homosexuality. 2. Review client's possible childhood sexual abuse history. 3. Encourage discussion of aversion to heterosexual relationships. 4. Explore client's family history of homosexuality.

ANS: 1 The nurse should initially self-assess personal attitudes toward homosexuality. The nurse must be able to recognize when negative feelings compromise care. Unconditional acceptance of each individual is an essential component of compassionate nursing.

A client diagnosed with schizophrenia spectrum disorder is prescribed clozapine (Clozaril). Which client symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately? 1. Sore throat, fever, and malaise 2. Akathisia and hypersalivation 3. Akinesia and insomnia 4. Dry mouth and urinary retention

ANS: 1 The nurse should intervene immediately if the client experiences signs of an infectious process—such as a sore throat, fever, and malaise—when taking the atypical antipsychotic drug clozapine. Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur, leading to infection.

A client requests information on several medications in order to make an informed choice about management of depression. A nurse should provide this information to facilitate which ethical principle? 1. Autonomy 2. Beneficence 3. Nonmaleficence 4. Justice

ANS: 1 The nurse should provide the information to support the client's autonomy. A client who is capable of making independent choices should be permitted to do so. In instances when clients are incapable of making informed decisions, a legal guardian or representative would be asked to give consent.

A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order? 1. History of alcohol use disorder 2. History of personality disorder 3. History of schizophrenia 4. History of hypertension

ANS: 1 The nurse should question a prescription of alprazolam for acute anxiety if the client has a history of alcohol use disorder. Alprazolam is a benzodiazepine used in the treatment of anxiety and has an increased risk for physiological dependence and tolerance. A client with a history of substance use disorder may be more likely to abuse other addictive substances.

To promote self-reliance, how should a psychiatric nurse best conduct medication administration? 1. Encourage clients to request their medications at the appropriate times. 2. Refuse to administer medications unless clients request them at the appropriate times. 3. Allow the clients to determine appropriate medication times. 4. Take medications to the clients' bedside at the appropriate times.

ANS: 1 The psychiatric nurse promoting self-reliance would encourage clients to request their medications at the appropriate times. Nurses are responsible for the management of medication administration on inpatient psychiatric units, but nurses must work with clients to encourage self-reliance and responsibility, which may result in independent decision-making, leading to medication adherence.

A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that teaching has been effective? 1. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder." 2. "Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder." 3. "Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks." 4. "Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks."

ANS: 1 The student indicates learning has occurred when he or she states that clonazepam is a particularly effective treatment for panic disorder. Clonazepam is a type of benzodiazepine in which the major risk is physical dependence and tolerance, which may encourage abuse. It can be used on an as-needed basis to reduce anxiety and its related symptoms.

Joey, age 8 years, takes methylphenidate (Ritalin) for attention deficit/hyperactivity disorder. His mother complains to the nurse that Joey has a very poor appetite, and she struggles to help him gain weight. What teaching will the nurse provide? 1. Administer Joey's medication immediately after meals. 2. Administer Joey's medication at bedtime. 3. Skip a dose of the medication when Joey does not eat anything. 4. Assure Joey's mother that Joey will eat when he is hungry.

ANS: 1 To reduce the anorexia associated with methylphenidate (Ritalin), the medication should be given after meals.

Which information suggests that caution is necessary in prescribing a benzodiazepine to an anxious client? 1. The client has a history of alcohol dependence. 2. The client has a history of diabetes mellitus. 3. The client has a history of schizophrenia. 4. The client has a history of hypertension.

ANS: 1 Tolerance and psychological dependence are common problems with the long-term use of benzodiazepines. They should be used cautiously with clients who have a history of substance abuse.

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

ANS: 1 Clients who have specific plans are at greater risk for suicide.

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

ANS: 1 The nurse should anticipate that the client of Jewish culture would place a high importance on preventative health care and would consider mental health as equally important to physical health.

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

ANS: 1 The nurse should determine that defense mechanisms can be appropriate during times of stress.

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

ANS: 1 The nurse should explain to the parents that, although the twins have identical DNA, there are several other factors that affect reactions to stress.

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

ANS: 1 The risk of suicide is greatly increased if the client has suicidal ideations, if the client has developed a plan, and particularly if the means exist for the client to execute the plan.

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

ANS: 1, 2, 3 Suicide of a family member can induce a whole gamut of feelings in the survivors, including shock. Suicide of a family member can induce a whole gamut of feelings in the survivors, including guilt. Suicide of a family member can induce a whole gamut of feelings in the survivors, including anger.

Which of the following nursing statements or questions represent appropriate communication to assess an individual in crisis? (Select all that apply.) 1. "Tell me what happened." 2. "What coping methods have you used, and did they work?" 3. "Describe to me what your life was like before this happened." 4. "Let's focus on the current problem." 5. "I'll assist you in selecting functional coping strategies."

ANS: 1, 2, 3 This is an appropriate statement to encourage the client to communicate. This statement enables the client to evaluate current coping strategies for effectiveness. This is an appropriate statement to encourage the client to communicate.

A client diagnosed with an adjustment disorder says to the nurse, "Tell me about medications that will cure this problem." Which of the following are appropriate nursing responses? (Select all that apply.) 1. "Medications can interfere with your ability to find a more permanent solution." 2. "Medications may mask the real problem at the root of this diagnosis." 3. "Adjustment disorders are not commonly treated with medications." 4. "Psychoactive drugs carry the potential for physiological and psychological dependence." 5. "Psychoactive drugs will be prescribed only if your problems persist for more than three months."

ANS: 1, 2, 3, 4 Adjustment disorders are not commonly treated with medications because of masking the real problem.

A nurse is admitting a client who has been diagnosed with PTSD. Which of the following symptoms might the nurse expect to assess? (Select all that apply.) 1. Feelings of guilt that precipitate social isolation 2. Aggressive behavior that affects job performance 3. Relationship problems 4. High levels of anxiety 5. Escalating symptoms lasting less than one month

ANS: 1, 2, 3, 4 Characteristic symptoms of PTSD.

The diagnosis of catatonic disorder associated with another medical condition is made when the client's medical history, physical examination, or laboratory findings provide evidence that symptoms are directly attributed to which of the following? (Select all that apply.) 1. Hyperthyroidism 2. Hypothyroidism 3. Hyperadrenalism 4. Hypoadrenalism 5. Hyperaphia

ANS: 1, 2, 3, 4 The diagnosis of catatonic disorder associated with another medical condition is made when the symptomatology is evidenced from medical history, physical examination, or laboratory findings to be directly attributable to the physiological consequences of a general medical condition. Types of medical conditions that have been associated with catatonic disorder include metabolic disorders, such as hypoadrenalism.

The nurse is preparing to assess a client before the physician prescribes a regimen of psychopharmacological therapy. Which components will the nurse assess? (Select all that apply.) 1. Medical history 2. Physical examination findings 3. Ethnocultural characteristics 4. Current medication

ANS: 1, 2, 3, 4 The nurse should assess medical history. The nurse should assess physical examination findings. The nurse should assess ethnocultural characteristics.

Which of the following individuals are communicating a message? (Select all that apply.) 1. A mother spanking her son for playing with matches 2. A teenage boy isolating himself and playing loud music 3. A biker sporting an eagle tattoo on his biceps 4. A teenage girl writing, "No one understands me" 5. A father checking for new email on a regular basis

ANS: 1, 2, 3, 4 The nurse should determine that a mother spanking her son for playing with matches is a way in which people communicate messages to others. The nurse should determine that a teenage boy isolating himself and playing loud music is a way in which people communicate messages to others. The nurse should determine that a biker sporting an eagle tattoo on his biceps is a way in which people communicate messages to others. The nurse should determine that writing is a way in which people communicate messages to others.

A client is diagnosed with erectile disorder. Which of the following medications would address this condition, and what is the therapeutic action of the drug? (Select all that apply.) 1. Phentolamine (Oraverse); increases blood flow to the penis 2. Apomorphine (Apokyn); acts directly on the dopamine receptors in the brain 3. Vardenafil (Levitra); blocks the action of phosphodiesterase-5 (PDE5) 4. Goserelin (Zoladex); inhibits the production of gonadotropins 5. Sildenafil (Viagra); blocks the action of phosphodiesterase-5 (PDE5)

ANS: 1, 2, 3, 5 Phentolamine has been used in combination with papaverine in an injectable form that increases blood flow to the penis, resulting in an erection. Apomorphine acts directly on the dopamine receptors in the brain. This mode of stimulating dopamine in the brain is thought to enhance the sexual response. Vardenafil (Levitra) was approved by the FDA for the treatment of erectile disorder. This newer impotence agent blocks the action of phosphodiesterase-5 (PDE5), an enzyme that breaks down cyclic guanosine monophosphate (cGMP), a compound that is required to produce an erection. Sildenafil (Viagra) blocks the action of phosphodiesterase-5 (PDE5).

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

ANS: 1, 2, 3, 5 SAMHSA suggests that a life in recovery is supported by four major dimensions, which include health, home, purpose, and community.

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

ANS: 1, 2, 4 Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments, upon which the Tidal Model is based. They include: Value the Voice, Respect the Language, Develop Genuine Curiosity, Become the Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be Transparent.

Which of the following interventions should a nurse use when caring for an inpatient client who expresses anger inappropriately? (Select all that apply.) 1. Maintain a calm demeanor. 2. Clearly delineate the consequences of the behavior. 3. Use therapeutic touch to convey empathy. 4. Set limits on the behavior. 5. Teach the client to avoid "I" statements related to expression of feelings.

ANS: 1, 2, 4 The nurse should determine that, when working with an inpatient client with difficulty expressing anger appropriately, it is important to maintain a calm demeanor. The nurse should determine that, when working with an inpatient client with difficulty expressing anger appropriately, it is important to clearly define the consequences. The nurse should determine that, when working with an inpatient client with difficulty expressing anger appropriately, it is important to set limits on the behavior.

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

ANS: 1, 2, 4 This symptom is a sign of anxiety. This is a symptom that the nurse would expect in a client experiencing anxiety. This option indicates anxiety.

Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia spectrum disorder? (Select all that apply.) 1. Group therapy 2. Medication management 3. Deterrent therapy 4. Supportive family therapy 5. Social skills training

ANS: 1, 2, 4, 5 The nurse should recognize that group therapy plays an integral part of rehabilitative programs for clients diagnosed with schizophrenia spectrum disorder. The nurse should recognize that medication management plays an integral part of rehabilitative programs for clients diagnosed with schizophrenia spectrum disorder. The nurse should recognize that supportive family therapy plays an integral part of rehabilitative programs for clients diagnosed with schizophrenia spectrum disorder. The nurse should recognize that social skills training plays an integral part of rehabilitative programs for clients diagnosed with schizophrenia spectrum disorder.

An attractive female client presents with high anxiety levels because of her belief that her facial features are large and grotesque. Body dysmorphic disorder (BDD) is suspected. Which of the following additional symptoms would support this diagnosis? (Select all that apply.) 1. Mirror checking 2. Excessive grooming 3. History of an eating disorder 4. History of delusional thinking 5. Skin picking

ANS: 1, 2, 5 The DSM-5 lists preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others as a diagnostic criterion for the diagnosis of BDD. Also listed is that at some point during the course of the disorder, the person has performed repetitive behaviors.

Which of the following characteristics should a nurse identify as "normal" in the development of human sexuality for an 11-year-old child? (Select all that apply.) 1. The child experiments with masturbation. 2. The child may experience homosexual play. 3. The child shows little interest in the opposite sex. 4. The child shows little concern about physical attractiveness. 5. The child is unlikely to want to undress in front of others.

ANS: 1, 2, 5 The nurse should identify that experimenting with masturbation is normal in the development of human sexuality in an 11-year-old child. The nurse should identify that homosexual play is normal in the development of human sexuality in an 11-year-old child. The nurse should identify that not wanting to undress in front of others is normal in the development of human sexuality in an 11-year-old child.

A nurse recognizes which of the following as the best predictors of PTSD in Vietnam veterans? (Select all that apply.) 1. The severity of the stressor 2. The degree of ego strength 3. The degree of psychosocial isolation in the recovery environment 4. The attitudes of society regarding the experience 5. The presence of preexisting psychopathology

ANS: 1, 3 In research with Vietnam veterans, it was shown that the best predictors of PTSD were the severity of the stressor and the degree of psychosocial isolation in the recovery environment.

A nurse is planning care for a child diagnosed with gender dysphoria. Which of the following nursing diagnoses could potentially document this client's problems? (Select all that apply.) 1. Low self-esteem R/T rejection by peers 2. Self-care deficit R/T isolative behaviors 3. Disturbed personal identity R/T parenting patterns 4. Impaired social interactions R/T socially unacceptable behaviors 5. Activity intolerance R/T fatigue

ANS: 1, 3, 4 Based on the data collected during a nursing assessment, possible nursing diagnoses for the child with gender dysphoria may include the following: low self-esteem related to rejection by peers. Based on the data collected during a nursing assessment, possible nursing diagnoses for the child with gender dysphoria may include the following: disturbed personal identity related to biological factors or parenting patterns that encourage culturally unacceptable behaviors for assigned gender. Based on the data collected during a nursing assessment, possible nursing diagnoses for the child with gender dysphoria may include the following: impaired social interaction related to socially and culturally unacceptable behaviors.

A nurse has been caring for a client diagnosed with generalized anxiety disorder. Which of the following nursing interventions would address this client's symptoms? (Select all that apply.) 1. Encourage the client to recognize the signs of escalating anxiety. 2. Encourage the client to avoid any situation that causes stress. 3. Encourage the client to employ newly learned relaxation techniques. 4. Encourage the client to cognitively reframe thoughts about situations that generate anxiety. 5. Encourage the client to avoid caffeinated products.

ANS: 1, 3, 4, 5 Nursing interventions that address GAD symptoms should include encouraging the client to recognize these symptoms.

Which of the following are behavior assessment categories in the Broset Violence Checklist? (Select all that apply.) 1. Confusion 2. Paranoia 3. Boisterousness 4. Panic 5. Irritability

ANS: 1, 3, 5 The Broset Violence Checklist is a quick, simple, and reliable tool that can be used to assess the risk of potential violence. One of the behavior assessment categories is confusion.

A college student has been diagnosed with generalized anxiety disorder. Which of the following symptoms should the campus nurse expect this client to exhibit? (Select all that apply.) 1. Fatigue 2. Anorexia 3. Hyperventilation 4. Insomnia 5. Irritability

ANS: 1, 4, 5 The nurse should expect that a client diagnosed with GAD would experience these symptoms.

After disturbing the peace, an aggressive, disoriented, unkempt, homeless individual is escorted to an emergency department. The client threatens suicide. Which of the following criteria would enable a physician to consider involuntary commitment? (Select all that apply.) 1. Being dangerous to others 2. Being homeless 3. Being disruptive to the community 4. Being gravely disabled and unable to meet basic needs 5. Being suicidal

ANS: 1, 4, 5 The physician could consider involuntary commitment when a client is dangerous to others. The physician could consider involuntary commitment when a client is gravely disabled. The physician could consider involuntary commitment when a client is suicidal.

Which is an example of an intentional tort? 1. A nurse fails to assess a client's obvious symptoms of neuroleptic malignant syndrome. 2. A nurse physically places an irritating client in four-point restraints. 3. A nurse makes a medication error and does not report the incident. 4. A nurse gives patient information to an unauthorized person.

ANS: 2 A tort, which can be intentional or unintentional, is a violation of civil law in which an individual has been wronged. A nurse who intentionally physically places an irritating client in restraints has touched the client without consent and has committed an intentional tort.

A client has been extremely nervous ever since a person died as a result of the client's drunk driving. When assessing for the diagnosis of AD, within what time frame should the nurse expect the client to exhibit symptoms? 1. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within 1 year of the accident. 2. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within 3 months of the accident. 3. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within 6 months of the accident. 4. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within 9 months of the accident.

ANS: 2 According to the DSM-5 diagnostic criteria for adjustment disorders, the development of emotional or behavioral symptoms in response to an identifiable stressor occurs within 3 months of the onset of the stressor.

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

ANS: 2 Although the elderly comprise less than 13 percent of the population, they account for 15 percent of all suicides

A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization? 1. The client will refrain from ritualistic behaviors during daylight hours. 2. The client will wake early enough to complete rituals prior to breakfast. 3. The client will participate in three unit activities by day three. 4. The client will substitute a productive activity for rituals by day one.

ANS: 2 An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to breakfast.

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

ANS: 2 Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 2: Awareness.

When used in combination with anxiolytic medication, alcohol leads to _____________ effects, and caffeine leads to _______________ effects. 1. increased; increased 2. increased; decreased 3. decreased; decreased 4. decreased; increased

ANS: 2 Anxiolytic medications work through depression of certain central nervous system (CNS) functions. Alcohol, which is a CNS depressant, would increase/potentiate their effects. Caffeine, which is a CNS stimulant, would decrease/inhibit their effects.

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

ANS: 2 Change in recovery is not an expedient process. It occurs incrementally over time.

A client receiving EMDR therapy says, "After only two sessions of my therapy, I am feeling great. Now I can stop and get on with my life." Which of the following nursing responses is most appropriate? 1. "I am thrilled that you have responded so rapidly to EMDR." 2. "To achieve lasting results, all eight phases of EMDR must be completed." 3. "If I were you, I would complete the EMDR and comply with doctor's orders." 4. "How do you feel about continuing the therapy?"

ANS: 2 Clients often feel relief quite rapidly with EMDR. However, to achieve lasting results, it is important that each of the eight phases be completed. The nurse's most appropriate response should be to give information to correct the client's misconceptions about the therapy.

A despondent client who has recently lost her husband of 30 years tearfully states, "I'll feel a lot better if I sell my house and move away." Which nursing response is most appropriate? 1. "I'm confident you know what's best for you." 2. "This may not be the best time for you to make such an important decision." 3. "Your children will be terribly disappointed." 4. "Tell me why you want to make this change."

ANS: 2 During crisis intervention, the nurse should guide the client through a problem-solving process. The nurse should help the individual confront the source of the problem, encourage the individual to discuss changes he or she would like to make, and encourage exploration of feelings about aspects of the crisis that cannot be changed.

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

ANS: 2 In examining a number of studies, Andresen and associates identified four components that were consistently evident in the recovery process. These components are hope, responsibility, self and identity, and meaning and purpose. Under responsibility, this model tasks the client, not the health-care team, with taking responsibility for his or her life and well-being.

After a teaching session about grief, a client says to the nurse, "I seem to be stuck in the anger stage of grieving over the loss of my son." How would the nurse assess this statement, and in what phase of the nursing process would this occur? 1. Assessment phase; nursing actions have been successful in achieving the objectives of care. 2. Evaluation phase; nursing actions have been successful in achieving the objectives of care. 3. Implementation phase; nursing actions have been successful in achieving the objectives of care. 4. Diagnosis phase; nursing actions have been successful in achieving the objectives of care.

ANS: 2 In the evaluation phase of the nursing process, reassessment is conducted to determine if the nursing actions have been successful in achieving the objectives of care. The implementation of client teaching has enabled the client to verbalize an understanding of the grief process and his or her position in the process. Therefore, the nurse's actions can be evaluated as successful. Without the evaluation phase, it would be difficult for the nurse to determine if actions have been successful.

Which statement about the tricyclic group of antidepressant medications is accurate? 1. Strong or aged cheese should not be eaten while taking them. 2. Their full therapeutic potential may not be reached until 4 weeks. 3. They may cause hypomania or recent memory impairment. 4. They should not be given with antianxiety agents.

ANS: 2 It may take several weeks for tricyclic medications to reach their full therapeutic effect.

A nursing instructor is explaining the etiology of trauma-related disorders from a learning theory perspective. Which student statement indicates that teaching has been effective? 1. "How clients perceive events and view the world affect their response to trauma." 2. "The psychic numbing in PTSD is a result of negative reinforcement." 3. "The individual becomes addicted to the trauma owing to an endogenous opioid response." 4. "Believing that the world is meaningful and controllable can protect an individual from PTSD."

ANS: 2 Learning theorists view negative reinforcement as behavior that leads to a reduction in an aversive experience, thereby reinforcing and resulting in repetition of the behavior. Psychic numbing decreases or protects an individual from emotional pain and, therefore, the learned response is the repetition of this behavior.

A client has been assigned a nursing diagnosis of complicated grieving related to the death of multiple family members in a motor vehicle accident. Which intervention should the nurse initially employ? 1. Encourage the journaling of feelings. 2. Assess for the stage of grief in which the client is fixed. 3. Provide community resources to address the client's concerns. 4. Encourage attending a grief therapy group.

ANS: 2 Prior to implementing all other nursing interventions presented, the nurse must assess the stage of grief in which the client is fixed. Appropriate nursing interventions are always based on accurate assessments.

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

ANS: 2 Recovery emerges from hope but affiliation with any particular religion would have little bearing on the recovery process.

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

ANS: 2 SAMHSA describes the dimension of home as a stable and safe place to live.

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

ANS: 2 SAMHSA lists the following as guiding principles for the recovery model: Recovery is based on respect.

During a hiring interview, which response by a nursing applicant should indicate that the applicant operates from an ethical egoism framework? 1. "I would want to be treated in a caring manner if I were mentally ill." 2. "This job will pay the bills, and the workload is light enough for me." 3. "I will be happy caring for the mentally ill. Working in med/surg kills my back." 4. "It is my duty in life to be a psychiatric nurse. It is the right thing to do."

ANS: 2 The applicant's comment reflects the ethical egoism framework. This framework promotes the idea that decisions are made based on what is good for the individual and may not take the needs of others into account.

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

ANS: 2 The basic concept of a recovery model is empowerment of the client. The recovery model is designed to allow clients primary control over decisions about their own care.

A mother rescues two of her four children from a house fire. In an emergency department, she cries, "I should have gone back in to get them. I should have died, not them." What is the nurse's best response? 1. "The smoke was too thick. You couldn't have gone back in." 2. "You're experiencing feelings of guilt, because you weren't able to save your children." 3. "Focus on the fact that you could have lost all four of your children." 4. "It's best if you try not to think about what happened. Try to move on."

ANS: 2 The best response by the nurse is, "You're experiencing feelings of guilt, because you weren't able to save your children." This response uses the therapeutic communication technique of restating what the client has said. This lets the client know whether an expressed statement has been understood or if clarification is necessary.

In response to a student's question regarding choosing a psychiatric specialty, a charge nurse states, "Mentally ill clients need special care. If I were in that position, I'd want a caring nurse also." From which ethical framework is the charge nurse operating? 1. Kantianism 2. Christian ethics 3. Ethical egoism 4. Utilitarianism

ANS: 2 The charge nurse is operating from a Christian ethics framework. The imperative demand of Christian ethics is that all decisions about right and wrong should be centered in love for God and in treating others with the same respect and dignity with which we would expect to be treated.

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

ANS: 2 The health-care provider should provide no more than a 3-day supply of Elavil with refills contingent on follow-up appointments as an appropriate intervention to maintain the client's safety. Tricyclic antidepressants have a narrow therapeutic range and can be used in overdose to commit suicide. Distributing limited amounts of the medication decreases this potential. In addition, clients may gain energy to carry out a suicide once they begin to have more energy from taking the antidepressants.

A client diagnosed with schizophrenia functions well and is bright, spontaneous, and interactive during hospitalization but then decompensates after discharge. What does the milieu provide that may be missing in the home environment? 1. Peer pressure 2. Structured programming 3. Visitor restrictions 4. Mandated activities

ANS: 2 The milieu, or therapeutic community, provides the client with structured programming that may be missing in the home environment. The therapeutic community provides a structured schedule of activities in which interpersonal interaction and communication with others are emphasized. Time is also devoted to personal problems and focus groups.

A nursing student questions an instructor regarding the order for fluvoxamine (Luvox) 300 mg daily for a client diagnosed with obsessive-compulsive disorder. Which instructor response is most accurate? 1. High doses of tricyclic medications will be required for effective treatment of OCD. 2. Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD. 3. The dose of Luvox is low because of the side effect of daytime drowsiness. 4. The dose of this SSRI is outside the therapeutic range and needs to be questioned.

ANS: 2 The most accurate instructor response is that SSRI doses in excess of what is effective for treating depression may be required in the treatment of OCD. SSRIs have been approved by the Food and Drug Administration for the treatment of OCD.

A family member is seeking advice about an older parent who seems to worry unnecessarily about everything. The family member states, "Should I seek psychiatric help for my mother?" Which is an appropriate nursing response? 1. "My mother also worries unnecessarily. I think it is part of the aging process." 2. "Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning." 3. "From what you have told me, you should get her to a psychiatrist as soon as possible." 4. "Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications."

ANS: 2 The most appropriate response by the nurse is to explain to the family member that anxiety is considered abnormal when it is out of proportion and impairs functioning. Anxiety is a normal reaction to a realistic danger or threat to biological integrity or self-concept.

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder? 1. Establishing personal contact with family members 2. Being reliable, honest, and consistent during interactions 3. Sharing limited personal information 4. Sitting close to the client to establish rapport

ANS: 2 The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the client's needs and maintain a calm attitude when dealing with agitated behavior.

Which situation exemplifies both assault and battery? 1. The nurse becomes angry, calls the client offensive names, and withholds treatment. 2. The nurse threatens to "tie down" the client and then does so, against the client's wishes. 3. The nurse hides the client's clothes and medicates the client to prevent elopement. 4. The nurse restrains the client without just cause and communicates this to family.

ANS: 2 The nurse in this situation has committed both the acts of assault and battery. Assault refers to an action that results in fear and apprehension that the person will be touched without consent. Battery is the touching of another person without consent.

An inpatient client with a known history of violence suddenly begins to pace. Which additional client behavior should alert a nurse to escalating anger and aggression? 1. The client requests prn medications. 2. The client has a tense facial expression and body language. 3. The client refuses to eat lunch. 4. The client sits in group with back to peers.

ANS: 2 The nurse should assess that tense facial expressions and body language may indicate that a client's anger is escalating.

A 52-year-old client states, "My husband is upset because I don't enjoy sex as much as I used to." Which priority client data should a nurse initially collect? 1. History of hysterectomy 2. Date of last menstrual cycle 3. Use of birth control methods 4. History of thought disorder

ANS: 2 The nurse should assess the client's last menstrual cycle to determine if the client is experiencing the onset of menopause. Menopause usually occurs around the age of 50. The decrease in estrogen can result in multiple symptoms, including a decrease in biological drives and sexual activity.

A nurse is counseling a client diagnosed with gender dysphoria. What criteria would differentiate this disorder from a transvestic disorder? 1. Clients diagnosed with transvestic disorder are dissatisfied with their gender, whereas clients diagnosed with gender dysphoria are not. 2. Clients diagnosed with gender dysphoria are dissatisfied with their gender, whereas clients diagnosed with transvestic disorder are not. 3. Clients diagnosed with gender dysphoria avoid all forms of sexual intercourse, whereas clients diagnosed with transvestic disorder do not. 4. Clients diagnosed with transvestic disorder avoid all forms of sexual intercourse, whereas clients diagnosed with gender dysphoria do not.

ANS: 2 The nurse should identify that clients diagnosed with gender dysphoria are dissatisfied with their gender, whereas clients diagnosed with transvestic disorder experience intense sexual arousal from dressing in the clothes of the opposite gender but are not dissatisfied with their gender.

A nurse maintains an uncrossed arm and leg posture when communicating with a client. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening? 1. S 2. O 3. L 4. E 5. R

ANS: 2 The nurse should identify that maintaining an uncrossed arm and leg posture is nonverbal behavior that reflects the O in the active-listening acronym SOLER.

A nurse is assessing a client diagnosed with pedophilic disorder. What would differentiate this sexual disorder from a sexual dysfunction? 1. Symptoms of sexual dysfunction include inappropriate sexual behaviors, whereas symptoms of a sexual disorder include impairment in normal sexual response. 2. Symptoms of a sexual disorder include inappropriate sexual behaviors, whereas symptoms of sexual dysfunction include impairment in normal sexual response. 3. Sexual dysfunction can be caused by increased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual disorders. 4. Sexual disorders can be caused by decreased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual dysfunction.

ANS: 2 The nurse should identify that pedophilic disorder is a sexual disorder in which individuals partake in inappropriate sexual behaviors. Pedophilic disorder involves having sexual urges, behaviors, or sexually arousing fantasies involving sexual activity with a prepubescent child.

Which potential client should a nurse identify as a candidate for involuntarily commitment? 1. The client living under a bridge in a cardboard box 2. The client threatening to commit suicide 3. The client who never bathes and wears a wool hat in the summer 4. The client who eats waste out of a garbage can

ANS: 2 The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatments is in danger and needs emergency treatment.

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

ANS: 2 The nurse should immediately intervene when a client exhibits aggressive behavior toward another client. Safety and security are considered lower-level needs according to Maslow's hierarchy of needs and must be fulfilled before other higher-level needs can be met.

What is the best rationale for including family in the client's therapy within the inpatient milieu? 1. To structure a program of social and work-related activities 2. To facilitate discharge from hospitalization 3. To provide a concrete demonstration of caring 4. To encourage the family to model positive behaviors

ANS: 2 The nurse should include the client's family in therapy within the inpatient milieu to facilitate discharge from the hospital. Family members are invited to participate in some therapy groups and to share meals with the client in the communal dining room. Family involvement may also serve to prevent the client from becoming too dependent on the therapeutic environment.

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

ANS: 2 The nurse should note escalating behaviors and intervene immediately, to maintain this client's safety. Early intervention may prevent an aggressive response and keep the client and others safe.

A widower reports a fear of intimacy because of an inability to achieve and sustain an erection. He has become isolative, has difficulty sleeping, and has lost weight over the past year. Which nursing diagnosis should be a priority for this client? 1. Risk for situational low self-esteem AEB inability to achieve an erection 2. Sexual dysfunction R/T dysfunctional grieving AEB inability to experience orgasm 3. Social isolation R/T low self-esteem AEB refusing to engage in dating activities 4. Disturbed body image R/T penile flaccidity AEB client statements

ANS: 2 The nurse should prioritize the nursing diagnosis sexual dysfunction R/T dysfunctional grieving AEB inability to experience orgasm. The nurse should assess the client's mood and level of energy, because depression and fatigue can decrease desire for participation in sexual activity.

A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? 1. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia. 2. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. 3. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia. 4. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.

ANS: 2 The nurse should recognize that positive symptoms of schizophrenia include, but are not limited to, paranoid delusions, neologisms, and echolalia.

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

ANS: 2 The nurse should understand that the client with psychosis experiences little distress owing to his or her lack of awareness of reality.

A client diagnosed with posttraumatic stress disorder related to a rape is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique might a nurse use that is an example of "broad openings"? 1. "What occurred prior to the rape, and when did you go to the emergency department?" 2. "What would you like to talk about?" 3. "I notice you seem uncomfortable discussing this." 4. "How can we help you feel safe during your stay here?"

ANS: 2 The nurse's statement, "What would you like to talk about?" is an example of the therapeutic communication technique of a broad opening. Using broad openings allows the client to take the initiative in introducing the topic and emphasizes the importance of the client's role in the interaction.

A nursing instructor is teaching about specific phobias. Which student statement indicates to the instructor that teaching has been effective? 1. "These clients recognize their fear as excessive and frequently seek treatment." 2. "These clients have a panic level of fear that is overwhelming and unreasonable." 3. "These clients experience symptoms that mirror a cerebrovascular accident." 4. "These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis."

ANS: 2 The nursing instructor should evaluate that learning has occurred when the student knows that clients with phobias have a panic level of fear that is overwhelming and unreasonable. Phobia is fear cued by a specific object or situation in which exposure to the stimuli produces an immediate anxiety response. Even though the disorder is relatively common among the general population, people seldom seek treatment unless the phobia interferes with ability to function.

A nursing instructor is teaching about the symptoms of agoraphobia. Which student statement indicates that teaching has been effective? 1. Onset of symptoms most commonly occurs in early adolescence and persists until midlife. 2. Onset of symptoms most commonly occurs in the 20s and 30s and persists for many years. 3. Onset of symptoms most commonly occurs in the 40s and 50s and persists until death. 4. Onset of symptoms most commonly occurs after the age of 60 and persists for at least 6 years.

ANS: 2 The onset of the symptoms of agoraphobia most commonly occurs in the 20s and 30s and persists for many years.

What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship? 1. Acknowledge the client's actions, and generate alternative behaviors. 2. Establish rapport and develop treatment goals. 3. Attempt to find alternative placement. 4. Explore how thoughts and feelings about this client may adversely impact nursing care.

ANS: 2 The priority nursing action during the orientation phase of the nurse-client relationship should be to establish rapport and develop treatment goals. Rapport implies feelings on the part of both the nurse and the client, based on respect, acceptance, a sense of trust, and a nonjudgmental attitude. It is the essential foundation of the nurse-client relationship.

Group therapy is strongly encouraged, but not mandatory, in an inpatient psychiatric unit. The unit manager's policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager's policy preserve? 1. Justice 2. Autonomy 3. Veracity 4. Beneficence

ANS: 2 The unit manager's policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. The principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that health-care workers must respect these decisions.

A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Which signs and symptoms of a potentially fatal side effect will the nurse teach the client about? 1. Blurring vision and muscular weakness 2. Sore throat, fever, and malaise 3. Tremor, shuffling gait, and rigidity 4. Fine tremor, tinnitus, and nausea

ANS: 2 These are symptoms of agranulocytosis, which is a potentially fatal disorder in which the client's white blood cell count drops to extremely low levels. This places the client at great risk for infections.

A client has been assigned an admission diagnosis of brief psychotic disorder. Which assessment information would alert the nurse to question this diagnosis? 1. The client has experienced impaired reality testing for a 24-hour period. 2. The client has experienced auditory hallucinations for the past 3 hours. 3. The client has experienced bizarre behavior for 1 day. 4. The client has experienced confusion for 3 weeks.

ANS: 2 This disorder is identified by the sudden onset of psychotic symptoms that may or may not be preceded by a severe psychosocial stressor. These symptoms last at least 1 day but less than 1 month.

A client was recently admitted to the inpatient unit after a suicide attempt. He has been placed on a tricyclic antidepressant. In terms of medication, what steps should be taken to maintain the client's safety when he is discharged? 1. Provide a 6-month supply to ensure long-term compliance. 2. Provide a 1-week supply of medication, with refills authorized only after he visits his provider. 3. Encourage him to increase fluid intake to counteract the common side effect of diarrhea. 4. Educate him not to eat foods that contain tyramine.

ANS: 2 To prevent suicide through overdose on antidepressant medication, a limited supply should be given at discharge. Clients with a history of depression who have a lifting of mood may have an increased risk for suicide. Giving the client a larger supply of antidepressant medication increases the chances of overdose.

A physician prescribes an additional medication for a client taking an antipsychotic agent. The medication is to be administered "prn for EPS." When will the nurse plan to give this medication? 1. When the client's white blood cell count falls below 3,000/mm3 2. When the client exhibits tremors and a shuffling gait 3. When the client complains of dry mouth 4. When the client experiences a seizure

ANS: 2 Tremors and a shuffling gait are examples of EPS.

When an individual is "two-faced," which characteristic—essential to the development of a therapeutic relationship—should a nurse identify as missing? 1. Respect 2. Genuineness 3. Sympathy 4. Rapport

ANS: 2 When an individual is "two-faced," which means double-dealing or deceitful, the nurse should identify that genuineness is missing in the relationship. Genuineness refers to the nurse's ability to be open and honest and maintain congruence between what is felt and what is communicated. When a nurse fails to bring genuineness to the relationship, trust cannot be established.

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

ANS: 2 Although the client has a history of suicide attempts, the current problem is isolative behaviors based on low self-esteem. Outcomes should be client-centered, specific, realistic, and measurable and contain a time frame.

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

ANS: 2 Bereavement following suicide is complicated by the complex psychological impact of the act on those close to the victim. Support groups for survivors can provide a meaningful resource for grief work.

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

ANS: 2 The client feels helpless to change his or her situation.

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

ANS: 2 The nurse should determine that the client is at risk for mental illness when responses to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed with a mental illness, daily functioning must be significantly impaired.

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

ANS: 2 This client has many risk factors for suicide. The client should have increased supervision to decrease likelihood of self-harm.

A nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. Which of the following commonly used behavioral therapies for phobias should the nurse explain to the client? (Select all that apply.) 1. Benzodiazepine therapy 2. Systematic desensitization 3. Imploding (flooding) 4. Assertiveness training 5. Aversion therapy

ANS: 2, 3 The nurse should explain to the client that systematic desensitization and imploding are the most common behavioral therapies used for treating phobias. Systematic desensitization involves the gradual exposure of the client to anxiety-provoking stimuli. The nurse should explain to the client that systematic desensitization and imploding are the most common behavioral therapies used for treating phobias. Imploding is the intervention used in which the client is exposed to extremely frightening stimuli for prolonged periods of time.

Which of the following characteristics should be included in a therapeutic nurse-client relationship? (Select all that apply.) 1. Meeting the psychological needs of the nurse and the client 2. Ensuring therapeutic termination 3. Promoting client insight into problematic behavior 4. Collaborating to set appropriate goals 5. Meeting both the physical and psychological needs of the client

ANS: 2, 3, 4, 5 The nurse-client therapeutic relationship should include ensuring therapeutic termination. The nurse-client therapeutic relationship should include promoting client insight into problematic behavior. The nurse-client therapeutic relationship should include collaborating to set appropriate goals. The nurse-client therapeutic relationship should include meeting both the physical and psychological needs of the client.

A family asks the nurse why their son was diagnosed with PTSD and others in the accident were not. Which of the following information should the nurse offer? (Select all that apply.) 1. An individual's religious affiliation can affect response to trauma. 2. Responses are affected by how an individual handled previous trauma. 3. Protectiveness of family and friends can help an individual deal with trauma. 4. Control over the possibility of recurrence can affect the response to trauma. 5. The time in which the trauma occurred can affect the individual's response.

ANS: 2, 3, 4, 5 Variables that affect whether an individual exposed to massive trauma develops trauma-related disorders are grouped into characteristics of the individual.

A nursing instructor is teaching about the various categories of paraphilic disorders. Which categories are correctly matched with expected behaviors? (Select all that apply.) 1. Exhibitionistic disorder: Mary models lingerie for a company that specializes in home parties. 2. Voyeuristic disorder: John is arrested for peering in a neighbor's bathroom window. 3. Frotteuristic disorder: Peter enjoys subway rush-hour female contact that results in arousal. 4. Pedophilic disorder: George can experience an orgasm by holding and feeling shoes. 5. Fetishistic disorder: Henry masturbates into his wife's silk panties.

ANS: 2, 3, 5 Categories of paraphilic disorders include voyeuristic disorder (observing unsuspecting people, who are naked, dressing, or engaged in sexual activity). Categories of paraphilic disorders include frotteuristic disorder (touching or rubbing against a non-consenting person). Categories of paraphilic disorders include fetishistic disorder (using nonliving objects in sexual ways).

A nurse attends an interdisciplinary team meeting regarding a newly admitted client. Which of the following individuals are typically included as members of the interdisciplinary treatment team in psychiatry? (Select all that apply.) 1. Respiratory therapist and psychiatrist 2. Occupational therapist and psychologist 3. Recreational therapist and art therapist 4. Social worker and hospital volunteer 5. Mental health technician and chaplain

ANS: 2, 3, 5 The occupational therapist and psychologist participate in the interdisciplinary treatment team. The recreational therapist and art therapist participate in the interdisciplinary treatment team. Mental health technician and chaplain participate in the interdisciplinary treatment team.

A client diagnosed with posttraumatic stress disorder (PTSD) states, "Why did my doctor prescribe an antidepressant rather than an antianxiety drug for me?" Which of the following are the most appropriate nursing responses? (Select all that apply.) 1. "I'm not sure, because antianxiety drugs have been approved by the FDA for PTSD." 2. "Antidepressants are now considered first-line treatment choice for PTSD." 3. "Many people have adverse reactions to antianxiety drugs." 4. "Because of their addictive properties, antianxiety drugs are less desirable." 5. "There have been no controlled studies on the effect of antianxiety drugs on PTSD."

ANS: 2, 4, 5 Paroxetine and sertraline (antidepressant drugs), not antianxiety drugs, have been approved by the FDA for the treatment of PTSD. Adverse reactions can occur with the use of anxiolytic drugs, but these reactions are not common. Their addictive properties make them less desirable than other medications used in the treatment of PTSD.

Which of the following conditions promote a therapeutic community? (Select all that apply.) 1. The unit schedule includes unlimited free time for personal reflection. 2. Unit responsibilities are assigned according to client capabilities. 3. A flexible schedule is determined by client needs. 4. The individual is the sole focus of therapy. 5. A democratic form of government exists.

ANS: 2, 5 A therapeutic community is promoted when unit responsibilities are assigned according to client capability. A therapeutic community is promoted when a democratic form of government exists.

How does a democratic form of self-government in the milieu contribute to client therapy? 1. By setting punishments for clients who violate the community rules 2. By dealing with inappropriate behaviors as they occur 3. By setting expectations wherein all clients are treated on an equal basis 4. By interacting with professional staff members to learn about therapeutic interventions

ANS: 3 A democratic form of self-government in the milieu contributes to client therapy by setting the expectation that all clients should be treated on an equal basis. Clients participate in the decision-making and problem-solving aspects that affect treatment setting. The norms, rules, and behavioral limits are established by the staff and clients.

The nurse is assessing a client who has a diagnosis of schizophrenia and takes an antipsychotic agent daily. Which finding requires further nursing assessment? 1. Respirations of 22 beats/minute 2. Weight gain of 8 lbs. in 2 months 3. Temperature of 101oF 4. Excess salivation

ANS: 3 A fever could be one of the first signs of an infection caused by reduced immunity from agranulocytosis secondary to antipsychotic medication.

Which client would a nurse recognize as being at highest risk for the development of an adjustment disorder? 1. A young married woman 2. An elderly unmarried man 3. A young unmarried woman 4. A young unmarried man

ANS: 3 Adjustment disorders are more common in women, unmarried persons, and younger people.

A client is diagnosed with schizophrenia spectrum disorder. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? 1. Tactile hallucinations 2. Tardive dyskinesia 3. Restlessness and muscle rigidity 4. Reports of hearing disturbing voices

ANS: 3 An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.

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

ANS: 3 Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments upon which the Tidal Model is based. They include: Be Transparent.

Which medication is most likely to be prescribed for the extrapyramidal side effects of antipsychotic medications? 1. Diazepam (Valium) 2. Amitriptyline (Elavil) 3. Benztropine (Cogentin) 4. Methylphenidate (Ritalin)

ANS: 3 Benztropine (Cogentin) is one of the most commonly used medications for extrapyramidal side effects.

A client was recently admitted to the inpatient unit after a suicide attempt and is prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse teaches the client about serotonin syndrome. Which of the following is a symptom of serotonin syndrome? 1. Change in mental status 2. Myoclonus 3. Blood pressure lability 4. Priapism

ANS: 3 Blood pressure lability is not a symptom of serotonin syndrome.

A nurse is assessing a client diagnosed with substance induced psychotic disorder (SIPD). What would differentiate this client's symptoms from the symptoms of a client diagnosed with brief psychotic disorder (BPD)? 1. Clients diagnosed with SIPD experience delusions, whereas clients diagnosed with BPD do not. 2. Clients diagnosed with BPD experience hallucinations, whereas clients diagnosed with SIPD do not. 3. Catatonic features may be associated with SIPD, whereas BPD has no catatonic features. 4. Catatonic features may be associated with BPD, whereas SIPD has no catatonic features.

ANS: 3 Catatonic features may be associated with SIPD, whereas BPD has no catatonic features.

Which nursing statement to a client about social anxiety disorder versus schizoid personality disorder (SPD) is most accurate? 1. "Clients diagnosed with social anxiety disorder can manage anxiety without medications, whereas clients diagnosed with SPD can only manage anxiety with medications." 2. "Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social anxiety disorder are not." 3. "Clients diagnosed with social anxiety disorder avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life." 4. "Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social anxiety disorder tend to avoid interactions in all areas of life."

ANS: 3 Clients diagnosed with social anxiety disorder avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. Social anxiety disorder is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others.

A client is diagnosed with anxiety disorder. Which medication is prescribed for anxiety? 1. Chlorpromazine (Thorazine) 2. Clozapine (Clozaril) 3. Diazepam (Valium) 4. Methylphenidate (Ritalin)

ANS: 3 Clozapine (Clozaril) is not an antianxiety agent.

A nurse is working with a client diagnosed with pedophilic disorder. Which client outcome is appropriate for the nurse to expect during the first week of hospitalization? 1. The client will verbalize an understanding of the importance of follow-up care. 2. The client will implement several relapse-prevention strategies. 3. The client will identify triggers for inappropriate behaviors. 4. The client will attend aversion therapy groups.

ANS: 3 During the first week of hospitalization, identifying triggers for inappropriate behaviors is an appropriate outcome for a client diagnosed with pedophilic disorder.

During her aunt's wake, a 4-year-old child runs up to the casket before her mother can stop her. An appointment is made with a nurse practitioner when the child starts twisting and pulling out hair. Which nursing diagnosis should the nurse practitioner assign to this child? 1. Complicated grieving 2. Altered family processes 3. Ineffective coping 4. Body image disturbance

ANS: 3 Ineffective coping is defined as an inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, or inability to use available resources. This child is coping with the anxiety generated by viewing her deceased aunt by pulling out hair. If this behavior continues, a diagnosis of hair-pulling disorder, or trichotillomania, may be assigned.

Both situational and intrapersonal factors most likely contribute to an individual's stress response. Which factor would a nurse categorize as intrapersonal? 1. Occupational opportunities 2. Economic conditions 3. Degree of flexibility 4. Availability of social supports

ANS: 3 Intrapersonal factors that might influence an individual's ability to adjust to a painful life change include social skills, coping strategies, the presence of psychiatric illness, degree of flexibility, and level of intelligence.

A nurse has been caring for a client diagnosed with PTSD. Which realistic goal should be included in this client's plan of care? 1. The client will have no flashbacks. 2. The client will be able to feel a full range of emotions by discharge. 3. The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge. 4. The client will refrain from discussing the traumatic event.

ANS: 3 Obtaining adequate sleep without zolpidem by discharge is a goal that should be included in the client's plan of care.

A nursing instructor is teaching about the Roberts' Seven-stage Crisis Intervention Model. Which nursing action should be identified with Stage IV? 1. Collaboratively implement an action plan. 2. Help the client identify the major problems or crisis precipitants. 3. Help the client deal with feelings and emotions. 4. Collaboratively generate and explore alternatives.

ANS: 3 Stage IV: Deal with Feelings and Emotions

An aging client with chronic schizophrenia takes a beta-adrenergic blocking agent (propranolol) for hypertension and an antipsychotic. Given the combined side effects of these drugs, what teaching should the nurse provide? 1. "Make sure you concentrate on taking slow, deep, cleansing breaths." 2. "Watch your diet and try to engage in some regular physical activity." 3. "Rise slowly when you change position from lying to sitting or sitting to standing." 4. "Wear sunscreen and try to avoid midday sun exposure."

ANS: 3 The antipsychotic medication can cause orthostatic hypotension that could be magnified by the propranolol.

As the sole survivor of a roadside bombing, a veteran is experiencing extreme guilt. Which nursing diagnosis would address this client's symptom? 1. Anxiety 2. Altered thought processes 3. Complicated grieving 4. Altered sensory perception

ANS: 3 The client's survivor guilt is disrupting the normal process of grieving.

A nurse is assessing a client diagnosed with sexual masochistic disorder. What would differentiate this paraphilic disorder from sexual sadistic disorder? 1. Symptoms of sexual masochistic disorder are chronic acts of humiliation, whereas symptoms of sexual sadistic disorder are acute. 2. Symptoms of sexual sadistic disorder are chronic acts of humiliation, whereas symptoms of sexual masochistic disorder are acute. 3. Masochistic acts can be performed alone, whereas sadistic acts must have a consenting or non-consenting partner. 4. Sadistic acts can be performed alone, whereas masochistic acts must have a consenting or nonconsenting partner.

ANS: 3 The identifying feature of sexual masochistic disorder is recurrent and intense sexual arousal when being humiliated, beaten, bound, or otherwise made to suffer. These masochistic activities may be fantasized and may be performed alone (e.g., self-inflicted pain) or with a partner. The identifying feature of sexual sadistic disorder is the recurrent and intense sexual arousal from the physical or psychological suffering of another individual.

An instructor is correcting a nursing student's clinical worksheet. Which instructor statement is the best example of effective feedback? 1. "Why did you use the client's name on your clinical worksheet?" 2. "You were very careless to refer to your client by name on your clinical worksheet." 3. "Surely you didn't do this deliberately, but you breeched confidentiality by using names." 4. "It is disappointing that after being told you're still using client names on your worksheet."

ANS: 3 The instructor's statement, "Surely you didn't do this deliberately, but you breeched confidentiality by using names," is an example of effective feedback. Feedback is method of communication for helping others consider a modification of behavior.

A female client on an inpatient unit enters the common area for visiting hours dressed in a see-through blouse. Which intervention should be a nurse's first priority? 1. Discuss with the client the inappropriateness of her attire. 2. Avoid addressing her attention-seeking behavior. 3. Lead the client back to her room and assist her with a change of clothing. 4. Restrict client to room until visiting hours are over.

ANS: 3 The most appropriate intervention by the nurse is to lead the client back to her room and assist her with a change of clothing. The client could be exhibiting symptoms of exhibitionistic disorder, which is characterized by urges to expose oneself to unsuspecting strangers.

A client diagnosed with schizophrenia spectrum disorder states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing response? 1. "Did you take your medicine this morning?" 2. "You are not going to hell. You are a good person." 3. "The voices must sound scary, but the devil is not talking to you. This is part of your illness." 4. "The devil only talks to people who are receptive to his influence."

ANS: 3 The most appropriate nursing response is to reassure the client while not reinforcing the hallucination. Reminding the client that "the voices" are a part of the illness is a way to help the client accept that the hallucinations are not real. It is also important for the nurse to connect with the client's fears and inner feelings.

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

ANS: 3 The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should accept that their child is experiencing the hallucination but should not reinforce this unreal sensory perception.

A client exhibiting dependent behaviors says, "Do you think I should move from my parent's house and get a job?" Which nursing response is most appropriate? 1. "It would be best to do that in order to increase independence." 2. "Why would you want to leave a secure home?" 3. "Let's discuss and explore all of your options." 4. "I'm afraid you would feel very guilty leaving your parents."

ANS: 3 The most appropriate response by the nurse is, "Let's discuss and explore all of your options." In this example, the nurse is encouraging the client to formulate ideas and decide independently the appropriate course of action.

An aging client diagnosed with schizophrenia spectrum disorder takes an antipsychotic and a beta-adrenergic blocking agent for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate? 1. "Make sure you concentrate on taking slow, deep, cleansing breaths." 2. "Watch your diet and try to engage in some regular physical activity." 3. "Rise slowly when you change position from lying to sitting or sitting to standing." 4. "Wear sunscreen and try to avoid midday sun exposure."

ANS: 3 The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, the additive effect of these drugs places the client at risk for developing orthostatic hypotension.

A client is experiencing a severe panic attack. Which nursing intervention would meet this client's physiological need? 1. Teach deep breathing relaxation exercises. 2. Place the client in a Trendelenburg position. 3. Have the client breathe into a paper bag. 4. Administer the ordered prn buspirone (BuSpar).

ANS: 3 The nurse can meet this client's physiological need by having the client breathe into a paper bag. Hyperventilation may occur during periods of extreme anxiety. Hyperventilation causes the amount of carbon dioxide (CO2) in the blood to decrease, possibly resulting in lightheadedness, rapid heart rate, shortness of breath, numbness or tingling in the hands or feet, and syncope. If hyperventilation occurs, assist the client to breathe into a small paper bag held over the mouth and nose. Six to 12 natural breaths should be taken, alternating with short periods of diaphragmatic breathing.

A brother calls to speak to his sister, who has been admitted to a psychiatric unit. The nurse connects him to the community phone, and the sister is summoned. Later the nurse realizes that the brother was not on the client's approved call list. What law has the nurse broken? 1. The National Alliance for the Mentally Ill Act 2. The Tarasoff Ruling 3. The Health Insurance Portability and Accountability Act 4. The Good Samaritan Law

ANS: 3 The nurse has violated HIPAA by revealing that the client had been admitted to the psychiatric unit. The nurse should not have provided any information without proper consent from the client.

Which therapeutic communication technique is being used in the following nurse-client interaction? Client: "When I am anxious, the only thing that calms me down is alcohol." Nurse: "Other than drinking, what alternatives have you explored to decrease anxiety?" 1. Reflecting 2. Making observations 3. Formulating a plan of action 4. Giving recognition

ANS: 3 The nurse is using the therapeutic communication technique of formulating a plan of action to help the client explore alternatives to drinking. The use of this technique may serve to prevent anger or anxiety from escalating.

A client is to undergo psychological testing. Which member of the interdisciplinary team should a nurse consult for this purpose? 1. The psychiatrist 2. The psychiatric social worker 3. The clinical psychologist 4. The clinical nurse specialist

ANS: 3 The nurse should consult with the clinical psychologist to obtain psychological testing for the client. Clinical psychologists can administer, interpret, and evaluate psychological tests to assist in the diagnostic process.

A paranoid client diagnosed with schizophrenia spectrum disorder states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom? 1. Magical thinking; administer an antipsychotic medication. 2. Persecutory delusions; orient the client to reality. 3. Command hallucinations; warn the psychiatrist. 4. Altered thought processes; call an emergency treatment team meeting.

ANS: 3 The nurse should determine that the client is exhibiting command hallucinations. The nurse's legal responsibility is to warn the psychiatrist of the potential for harm. Clients demonstrating a risk for violence could potentially be physically, emotionally, and/or sexually harmful to others or to self.

A client living in a beachfront community is seeking help with an extreme fear of bridges, which is interfering with daily functioning. The psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this treatment should the nurse provide? 1. "Using your imagination, we will attempt to achieve a state of relaxation." 2. "Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response." 3. "Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety." 4. "In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate."

ANS: 3 The nurse should explain to the client that when participating in systematic desensitization, he or she will go through a series of increasingly anxiety-provoking steps that will gradually increase tolerance. Systematic desensitization was introduced by Joseph Wolpe in 1958 and is based on behavioral conditioning principles.

Which treatment should the nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder? 1. Long-term treatment with diazepam (Valium) 2. Acute symptom control with citalopram (Celexa) 3. Long-term treatment with buspirone (BuSpar) 4. Acute symptom control with ziprasidone (Geodon)

ANS: 3 The nurse should identify that an appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients diagnosed with GAD. Buspirone takes 10 to 14 days for alleviation of symptoms but does not have the dependency concerns of other anxiolytics.

Which client statement should a nurse identify as a typical response to stress most often experienced in the working phase of the nurse-client relationship? 1. "I can't bear the thought of leaving here and failing." 2. "I might have a hard time working with you, because you remind me of my mother." 3. "I really don't want to talk any more about my childhood abuse." 4. "I'm not sure that I can count on you to protect my confidentiality."

ANS: 3 The nurse should identify that the client statement, "I really don't want to talk any more about my childhood abuse," reflects that the client is in the working phase of the nurse-client relationship. The working phase includes overcoming resistance behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues.

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

ANS: 3 The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients to communicate needs and to establish relationships.

A client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client? 1. Disturbed sensory perception 2. Altered thought processes 3. Risk for violence: directed toward others 4. Risk for injury

ANS: 3 The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices commanding him to kill someone is at risk for other-directed violence. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.

A client who will be receiving ECT must provide informed consent. Which situation should cause a nurse to question the validity of the informed consent? 1. The client is paranoid. 2. The client is 87 years old. 3. The client incorrectly reports his or her spouse's name, date, and time of day. 4. The client relies on his or her spouse to interpret the information.

ANS: 3 The nurse should question the validity of informed consent when the client incorrectly reports the spouse's name, date, and time of day. This indicates that this client is disoriented and may not be competent to make informed choices.

Which situation reflects violation of the ethical principle of veracity? 1. A nurse discusses with a client another client's impending discharge. 2. A nurse refuses to give information to a physician who is not responsible for the client's care. 3. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room. 4. A nurse does not treat all of the clients equally, regardless of illness severity.

ANS: 3 The nurse who tricks a client into seclusion has violated the ethical principle of veracity. The principle of veracity refers to one's duty to always be truthful and not intentionally deceive or mislead clients.

A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the client's wishes? 1. A client makes inappropriate sexual innuendos to a staff member. 2. A client constantly demands attention from the nurse by begging, "Help me get better." 3. A client physically attacks another client after being confronted in group therapy. 4. A client refuses to bathe or perform hygienic activities.

ANS: 3 The nurse would have the right to medicate a client against his or her wishes if the client physically attacks another client. This client poses a significant risk to safety and is incapable of making informed choices. The client's refusal to accept treatment can be challenged, because the client is endangering the safety of others.

An angry client on an inpatient unit approaches a nurse stating, "Someone took my lunch! People need to respect others, and you need to do something about this now!" The nurse's response should be guided by which basic assumption of milieu therapy? 1. Conflict should be avoided at all costs on inpatient psychiatric units. 2. Conflict should be resolved by the nursing staff. 3. On inpatient units, every interaction is an opportunity for therapeutic intervention. 4. Conflict resolution should only be addressed during group therapy.

ANS: 3 The nurse's response should be guided by the basic assumption that every interaction is an opportunity for therapeutic intervention.

The nurse is interviewing a newly admitted psychiatric client. Which of the following nursing statements is an example of offering a "general lead"? 1. "Do you know why you are here?" 2. "Are you feeling depressed or anxious?" 3. "Yes, I see. Go on." 4. "Can you order the specific events that led to your admission?"

ANS: 3 The nurse's statement, "Yes, I see. Go on," is an example of a general lead. Offering general leads encourages the client to continue sharing information.

A college student is unable to take a final exam due to severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should the campus nurse assign for this client? 1. Non-adherence R/T test taking 2. Ineffective role performance R/T helplessness 3. Altered coping R/T anxiety 4. Powerlessness R/T fear

ANS: 3 The priority nursing diagnosis for this client is altered coping R/T anxiety. The nurse should assist in implementing interventions that will improve the client's healthy coping skills and reduce anxiety.

A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the priority nursing diagnosis for this client? 1. Ineffective coping R/T situational crisis AEB powerlessness 2. Anxiety R/T fear of failure 3. Risk for self-directed violence R/T hopelessness 4. Risk for low self-esteem R/T loss events AEB suicidal ideations

ANS: 3 The priority nursing diagnosis for this client is risk for self-directed violence R/T hopelessness. Nurses should prioritize diagnoses and outcomes based on potential safety risk to the client or others.

A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago and asks why he has gained 12 lbs. since then. Which is the appropriate nursing response? 1. "I'm surprised you have gained; weight loss is the typical pattern when taking lithium." 2. "Your weight gain is more likely related to food intake than medication." 3. "Weight gain is a common, but troubling side effect. Let's talk about some strategies for safely improving your nutrition and exercise habits." 4. "There's not much you can do about the weight gain. It's better than being emotionally unstable, though."

ANS: 3 Weight gain is a common side effect of lithium therapy. To ensure compliance the nurse should help the client develop strategies to prevent excessive weight gain.

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

ANS: 3 A degree of the responsibility for the suicidal client's safety is given to the client. When a client shares with staff a plan for suicide, the client is participating in a plan for safety by communicating thoughts of self-harm that would initiate interventions to prevent suicide.

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

ANS: 3 A history of suicide attempts places a client at a higher risk for current suicide behaviors. Knowing this specific data will alert the nurse to the client's risk. Of those who commit suicide, 50-80 percent had a previous attempt.

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

ANS: 3 An atheist does not believe in punishment for suicide by a higher power.

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

ANS: 3 Suicide is a behavior.

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

ANS: 3 The new DSM-5 definition of a mental disorder is "A health condition characterized by significant dysfunction in an individual's cognitions, or behaviors that reflect a disturbance in the psychological, biological, or developmental process underlying mental functioning."

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

ANS: 3 The nurse should attempt to educate the client on the negative effects of excessive stress on medical conditions.

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

ANS: 3 The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behaviors prior to attaining the full therapeutic effect of the antidepressant medication.

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

ANS: 3 The nurse should evaluate that the client is in the acceptance stage of grief because during this stage of the grief process, the client would be able to focus on the reality of the loss and its meaning in relation to life.

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

ANS: 3 The nurse should expect that the client using the defense mechanism displacement would criticize a coworker after being confronted by the boss.

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

ANS: 3 The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors.

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

ANS: 3 The nurse should identify that the client who possesses a feeling of self-fulfillment and realizes his or her full potential has achieved self-actualization, the highest level on Maslow's hierarchy of needs.

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

ANS: 3 The nurse should observe the actively suicidal client continuously for the first hour after admission. After a full assessment the treatment team will determine the observation status of the client. Observation of the client allows the nurse to interrupt any observed suicidal behaviors.

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

ANS: 3 The nurse's priority intervention when a client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideation.

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

ANS: 3 The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. The appropriate nursing diagnosis for this client would be risk for suicide.

Which clinical presentation is associated with the most commonly diagnosed adjustment disorder (AD)? 1. Anxiety, feelings of hopelessness, and worry 2. Truancy, vandalism, and fighting 3. Nervousness, worry, and jitteriness 4. Depressed mood, tearfulness, and hopelessness

ANS: 4 AD with depressed mood is the most commonly diagnosed adjustment disorder. The clinical presentation is one of predominant mood disturbance, although less pronounced than that of major depression. The symptoms—such as depressed mood, tearfulness, and feelings of hopelessness—exceed what is an expected or normative response to an identified stressor.

Which medication does not require periodic blood-level monitoring? 1. Eskalith (lithium carbonate) 2. Depakote (valproic acid) 3. Clozaril (clozapine) 4. Paxil (paroxetine)

ANS: 4 Blood level monitoring is usually not done for Paxil (paroxetine).

A client takes a maintenance dosage of lithium carbonate for a bipolar disorder. She has come to the community health clinic, stating that she "has had the flu for over a week." She describes her symptoms as coughing, runny nose, chest congestion, fever, and gastrointestinal upset. Her temperature is 100.9°F. What situation does the nurse anticipate? 1. She has consumed some foods high in tyramine. 2. She has stopped taking her lithium carbonate. 3. She has probably developed a tolerance to the lithium carbonate. 4. The lithium carbonate may be producing symptoms of toxicity.

ANS: 4 Blurred vision, gastrointestinal upset, and tinnitus are symptoms of lithium toxicity.

As part of discharge teaching, which guideline regarding lithium therapy will the nurse plan to include? 1. Avoid excessive use of beverages containing caffeine. 2. Maintain a consistent sodium intake. 3. Consume at least 2,500 to 3,000 mL of fluid per day. 4. All of the above

ANS: 4 Caffeine, a stimulant, should be limited in clients with mania. Adequate sodium and fluid intake is necessary to prevent lithium toxicity.

Eye movement desensitization and reprocessing (EMDR) has been empirically validated for which disorder? 1. Adjustment disorder 2. Generalized anxiety disorder 3. Panic disorder 4. Posttraumatic stress disorder

ANS: 4 EMDR has been used for depression, adjustment disorder, phobias, addictions, generalized anxiety disorder, and panic disorder. However, at present, EMDR has only been empirically validated for trauma-related disorders, such as PTSD and acute stress disorder.

The nurse is providing education to a client diagnosed with anxiety. Which statement by the client indicates that teaching has been effective? 1. "There is nothing that I can do to that will reduce anxiety." 2. "Medication is available, but only for those who have had anxiety for a year or more." 3. "If I ignore the symptoms of anxiety, it will go away." 4. "Practicing yoga or meditation may help reduce my anxiety."

ANS: 4 Practicing yoga or meditation may help reduce the symptoms of anxiety.

A 20-year-old client and a 60-year-old client have had drunk driving accidents and are both experiencing extreme anxiety. From a psychosocial theory perspective, which of these clients would be predisposed to the diagnosis of adjustment disorder? 1. The 60-year-old, because of memory deficits 2. The 60-year-old, because of decreased cognitive processing ability 3. The 20-year-old, because of limited cognitive experiences 4. The 20-year-old, because of lack of developmental maturity

ANS: 4 Research indicates that there is a predisposition to the diagnosis of adjustment disorder when there is limited developmental maturity. By comparison, the 20-year-old does not have the developmental maturity, life experiences, and coping mechanisms that the 60-year-old might possess.

A nursing instructor is teaching about trauma and stressor-related disorders. Which statement by one of the students indicates that further instruction is needed? 1. "The trauma that women experience is more likely to be sexual assault and child sexual abuse." 2. "The trauma that men experience is more likely to be accidents, physical assaults, combat, or viewing death or injury." 3. "After exposure to a traumatic event, only 10 percent of victims develop posttraumatic stress disorder (PTSD)." 4. "Research shows that PTSD is more common in men than in women."

ANS: 4 Research shows that PTSD is more common in women than in men. This student statement indicates a need for further instruction.

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

ANS: 4 The WRAP recovery model is a step-wise process through which an individual is able to monitor and manage distressing symptoms that occur in daily life. The six steps include: In step 6 (Crisis Planning), clients can no longer care for themselves, make independent decisions, or keep themselves safe. Caregivers take an active role in this step on behalf of the client and implement the plan that the client has previously developed.

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

ANS: 4 The basic concept of a recovery model is empowerment of the consumer. The recovery model is designed to allow consumers primary control over decisions about their own care.

A client, who recently delivered a stillborn baby, has a diagnosis of adjustment disorder unspecified. The nurse case manager should expect which client presentation that is characteristic of this diagnosis? 1. The client worries continually and appears nervous and jittery. 2. The client complains of a depressed mood, is tearful, and feels hopeless. 3. The client is belligerent, violates others' rights, and defaults on legal responsibilities. 4. The client complains of many physical ailments, refuses to socialize, and quits her job.

ANS: 4 The diagnosis of adjustment disorder unspecified is assigned when the maladaptive reaction is not consistent with any of the other categories. Manifestations may include physical complaints, social withdrawal, or work or academic inhibition, without significant depressed or anxious mood.

When planning care for a client diagnosed with female sexual interest/arousal disorder, what should the nurse document as an expected outcome of sensate focus exercises? 1. To initiate immediate orgasm 2. To reduce anxiety by eliminating physical touch 3. To focus on touching breasts and genitals 4. To reduce goal-oriented demands of intercourse

ANS: 4 The expected outcome of sensate focus exercises is to reduce goal-oriented demands of intercourse. The reduction in demands reduces performance pressures and anxiety associated with possible failure.

A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client? 1. The client is placed in seclusion. 2. The client is placed in a geriatric chair with tray. 3. The client is placed in soft Posey restraints. 4. The client is monitored by an ankle bracelet.

ANS: 4 The least-restrictive alternative for this client would be monitoring by an ankle bracelet.

An involuntarily committed client is verbally abusive to the staff, repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit? 1. Verbally redirect the client, and then refuse one-on-one interaction. 2. Involve the hospital's security division as soon as possible. 3. Notify the client that documenting personal staff information is against hospital policy. 4. Continue professional attempts to establish a positive working relationship with the client.

ANS: 4 The most appropriate nursing action is to continue professional attempts to establish a positive working relationship with the client.

Which nursing intervention would be most appropriate when caring for an acutely agitated paranoid client diagnosed with schizophrenia spectrum disorder? 1. Provide neon lights and soft music. 2. Maintain continual eye contact throughout the interview. 3. Use therapeutic touch to increase trust and rapport. 4. Provide personal space to respect the client's boundaries.

ANS: 4 The most appropriate nursing intervention is to provide personal space to respect the client's boundaries. Providing personal space may serve to reduce anxiety and thus reduce the client's risk for violence. The nurse should observe the patient while carrying out routine tasks.

An involuntarily committed client, when offered a dinner tray, pushes it off the bedside table onto the floor. Which nursing intervention should a nurse implement to address this behavior? 1. Initiate forced medication protocol. 2. Help the client to explore the source of anger. 3. Ignore the act to avoid reinforcing the behavior. 4. With staff support and a show of solidarity, set firm limits on the behavior.

ANS: 4 The most appropriate nursing intervention is to set firm limits on the behavior.

A client on an inpatient unit angrily says to a nurse, "Peter is not cleaning up after himself in the community bathroom. You need to address this problem." Which is the appropriate nursing response? 1. "I'll talk to Peter and present your concerns." 2. "Why are you overreacting to this issue?" 3. "You should bring this to the attention of your treatment team." 4. "I can see that you are angry. Let's discuss ways to approach Peter with your concerns."

ANS: 4 The most appropriate nursing response involves restating the client's feeling and developing a plan with the client to solve the problem. According to Skinner, every interaction is an opportunity for therapeutic intervention to improve communication and relationship-development skills.

A newly admitted client, diagnosed with obsessive-compulsive disorder (OCD), washes his hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation? 1. "Everyone diagnosed with OCD needs to control their ritualistic behaviors." 2. "It is important for you to discontinue these ritualistic behaviors." 3. "Why are you asking for help, if you won't participate in unit therapy?" 4. "Let's figure out a way for you to attend unit activities and still wash your hands."

ANS: 4 The most appropriate statement by the nurse is, "Let's figure out a way for you to attend unit activities and still wash your hands." This statement reflects the therapeutic communication technique of formulating a plan of action. The nurse attempts to work with the client to develop a plan without damaging the therapeutic relationship.

A nurse is assessing a client diagnosed with schizophrenia spectrum disorder. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" The nurse is assessing which potential symptom of this disorder? 1. Thought insertion 2. Paranoid delusions 3. Magical thinking 4. Delusions of reference

ANS: 4 The nurse is assessing for the potential symptom of delusions of reference. A client that believes he or she receives messages through the radio is experiencing delusions of reference. These delusions involve the client interpreting events within the environment as being directed toward himself or herself. Clients with delusions of reference believe that others are trying to send them messages in various ways, or they must break a code to receive a message.

What is the best nursing rationale for holding a debriefing session with clients and staff after a take-down intervention has taken place in an inpatient unit? 1. Reinforce unit rules with the client population. 2. Create protocols for the future release of tensions associated with anger. 3. Process client feelings and alleviate fears of undeserved seclusion and restraint. 4. Discuss the situation that led to inappropriate expressions of anger.

ANS: 4 The nurse should determine that the purpose for holding a debriefing session with clients and staff after a take-down intervention is to discuss the situation that led to inappropriate behavior. It is important to determine the factors leading to the inappropriate behavior in order to develop future intervention strategies. It is also important to help clients and staff process feelings about the situation.

A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client's problem? 1. Distract the client with other activities whenever ritual behaviors begin. 2. Report the behavior to the psychiatrist to obtain an order for medication dosage increase. 3. Lock the room to discourage ritualistic behavior. 4. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

ANS: 4 The nurse should discuss with the client the anxiety-provoking triggers that precipitate the ritualistic behavior. If the client is going to be able to control interrupting anxiety, he or she must first learn to recognize precipitating factors.

A college student, who was nearly raped while jogging, completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met? 1. "You've really been helpful. Can I count on you for continued support?" 2. "I work out in the college gym rather than jogging outdoors." 3. "I'm really glad I didn't go home. It would have been hard to come back." 4. "I carry mace when I jog. It makes me feel safe and secure."

ANS: 4 The nurse should evaluate that the client who has developed adaptive coping strategies has achieved the goals of crisis intervention. The final phase of crisis intervention involves evaluating the outcome of the crisis intervention and anticipatory planning.

A client comes to a psychiatric clinic experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What long-term outcome is realistic in addressing this client's crisis? 1. The client will change his type-A personality traits to more adaptive ones by one week. 2. The client will list five positive self-attributes. 3. The client will examine how childhood events led to his overachieving orientation. 4. The client will return to previous adaptive levels of functioning by week six.

ANS: 4 The nurse should identify that a realistic long-term outcome for this client is to return to previous adaptive levels of functioning. The nurse should work with the client to develop attainable outcomes that reflect immediacy of the situation.

A nurse working on an inpatient psychiatric unit is assigned to conduct a 45-minute education group. What should the nurse identify as an appropriate group topic? 1. Dream analysis 2. Creative cooking 3. Paint by number 4. Stress management

ANS: 4 The nurse should identify that teaching clients about stress management is an appropriate education group topic. Nurses should be able to perform the role of client teacher in the psychiatric area. Nurses need to be able to assess a client's learning readiness. Other topics for education groups include medical diagnoses, side effects of medications, and the importance of medication adherence.

On which task should a nurse place priority during the working phase of relationship development? 1. Establishing a contract for intervention 2. Examining feelings about working with a particular client 3. Establishing a plan for continuing aftercare 4. Promoting the client's insight and perception of reality

ANS: 4 The nurse should place priority on promoting the client's insight and perception of reality during the working phase of relationship development.

What symptoms should the nurse recognize that differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? 1. GAD is acute in nature, and panic disorder is chronic. 2. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. 3. Hyperventilation is a common symptom in GAD and rare in panic disorder. 4. Depersonalization is commonly seen in panic disorder and absent in GAD.

ANS: 4 The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.

If a client demonstrates transference toward a nurse, how should the nurse respond? 1. Promote safety and immediately terminate the relationship with the client. 2. Encourage the client to ignore these thoughts and feelings. 3. Immediately reassign the client to another staff member. 4. Help the client to clarify the meaning of the relationship, based on the present situation.

ANS: 4 The nurse should respond to a client's transference by clarifying the meaning of the nurse-client relationship based on the present situation. Transference occurs when the client unconsciously displaces feelings about a person from the past toward the nurse.

A cab driver, stuck in traffic, becomes lightheaded, tremulous, diaphoretic, tachycardic, and dyspneic. A work-up in an emergency department reveals no pathology. Which medical diagnosis should the nurse suspect, and what nursing diagnosis should be the nurse's first priority? 1. Generalized anxiety disorder and a nursing diagnosis of fear 2. Mild anxiety disorder and a nursing diagnosis of anxiety 3. Pain disorder and a nursing diagnosis of altered role performance 4. Panic disorder and a nursing diagnosis of anxiety

ANS: 4 The nurse should suspect that the client has exhibited signs and symptoms of a panic disorder. The priority nursing diagnosis should be anxiety. Panic disorder is characterized by recurrent, sudden-onset panic attacks in which the person feels intense fear, apprehension, or terror.

Which statement should a nurse identify as correct regarding a client's right to refuse treatment? 1. Clients can refuse pharmacological but not psychological treatment. 2. Clients can refuse any treatment at any time. 3. Clients can refuse only electroconvulsive therapy (ECT). 4. Professionals can override treatment refusal by an actively suicidal or homicidal client.

ANS: 4 The nurse should understand that health-care professionals can override treatment refusal when a client is actively suicidal or homicidal. A suicidal or homicidal client who refuses treatment may be in danger or a danger to others. This situation should be treated as an emergency, and treatment may be performed without informed consent.

A new mother is concerned about her ability to perform her parental role. She is quite anxious and ambivalent about leaving the postpartum unit. To offer effective client care, a nurse should be familiar with what information about this type of crisis? 1. This type of crisis is precipitated by unexpected external stressors. 2. This type of crisis is precipitated by preexisting psychopathology. 3. This type of crisis is precipitated by an acute response to an external situational stressor. 4. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.

ANS: 4 The nurse should understand that this type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. Reassurance and guidance should be provided as needed, and the client should be referred to services that can provide assistance.

A mother who is notified that her child was killed in a tragic car accident states, "I can't bear to go on with my life." Which nursing statement conveys empathy? 1. "This situation is very sad, but time is a great healer." 2. "You are sad, but you must be strong for your other children." 3. "Once you cry it all out, things will seem so much better." 4. "It must be horrible to lose a child, and I'll stay with you until your husband arrives."

ANS: 4 The nurse's response, "It must be horrible to lose a child, and I'll stay with you until your husband arrives," conveys empathy to the client. Empathy is the ability to see the situation from the client's point of view. Empathy is considered to be one of the most important characteristics of the therapeutic relationship.

A nurse says to a client, "Things will look better tomorrow after a good night's sleep." This is an example of which communication technique? 1. The therapeutic technique of giving advice 2. The therapeutic technique of defending 3. The nontherapeutic technique of presenting reality 4. The nontherapeutic technique of giving reassurance

ANS: 4 The nurse's statement, "Things will look better tomorrow after a good night's sleep," is an example of the nontherapeutic communication technique of giving reassurance. Giving reassurance indicates to the client that there is no cause for anxiety, thereby devaluing the client's feelings.

What is a nurse's purpose for providing appropriate feedback? 1. To give the client good advice 2. To advise the client on appropriate behaviors 3. To evaluate the client's behavior 4. To give the client critical information

ANS: 4 The purpose of providing appropriate feedback is to give the client critical information.

A client is experiencing a psychotic episode. He is in good physical health but has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Which antipsychotic medication would be contraindicated for the client? 1. Haloperidol, because it is used only in elderly patients 2. Clozapine, because it is incompatible with desipramine 3. Risperidone, because it exacerbates symptoms of depression 4. Thioridazine, because of cross-sensitivity among phenothiazines

ANS: 4 There may be cross-sensitivity among phenothiazines. Both prochlorperazine (Compazine) and thioridazine (Mellaril) are phenothiazines. Since the client has a known allergy to one phenothiazine, he should not be given another phenothiazine.

A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Which blood cell counts would reveal a potentially fatal side effect of this medication? 1. WBCs, >3,000/mm3; granulocytes, >2,000/mm3 2. WBCs, <3,000/mm3; granulocytes, >2,000/mm3 3. WBCs, >3,000/mm3; granulocytes, <2,000/mm3 4. WBCs, <3,000/mm3; granulocytes, <2,000/mm3

ANS: 4 These blood test results are indicative of agranulocytosis, a potentially fatal disorder in which the client's white blood cell count drops to extremely low levels.

A client was admitted with major depression that was a single episode and moderate. During her stay, she was started on Prozac (fluoxetine) at 40 mg orally every day. The nurse's discharge teaching should include all of the following except: 1. Continue taking Prozac as prescribed. You will continue to see improvement over the next few weeks. 2. Make sure that you follow up with outpatient psychotherapy as you and the social worker have arranged. 3. You may be able to discontinue the medication within 6 months to 1 year, but only under a doctor's supervision. However, there is a chance of recurring episodes. 4. You should avoid foods with tyramine, including beer, beans, processed meats, and red wine.

ANS: 4 This is true regarding MAOIs, not an SSRI antidepressant, such as fluoxetine.

A client was recently admitted to the inpatient unit after a suicide attempt and has not responded to SSRIs or tricyclic antidepressants. The client asks the nurse, "I heard about monoamine oxidase inhibitors (MAOIs). Why can't they be added to what I am on now? Wouldn't adding one help?" Which is the appropriate nursing response? 1. "Electroconvulsive therapy is your best option at this point." 2. "Combined use can lead to a life-threatening condition called hypertensive crisis." 3. "There is no reason why an MAOI couldn't be added to your therapy." 4. "They can't be used together because their mechanisms of action are very different."

ANS: 4 This statement is not therapeutic or accurate.

A client has been diagnosed with major depression and is prescribed imipramine (Tofranil). What information specifically related to this class of antidepressants will the nurse plan to include in client and family education? 1. The medication may cause dry mouth. 2. The medication may cause nausea. 3. The medication should not be discontinued abruptly. 4. The medication may cause photosensitivity.

ANS: 4 Tricyclic antidepressants cause photosensitivity.

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

ANS: 4 Assessment is the first step of the nursing process to gain needed information to determine further appropriate interventions. Suicide risk assessment should always be the first step taken when working with depressed or suicidal patients.

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

ANS: 4 Being available to actively listen, support, and accept feelings increases the potential that a client would confide suicidal ideations to family members.

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

ANS: 4 It is a fact that between 50 and 80 percent of all people who kill themselves have a history with a previous attempt.

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

ANS: 4 Participation in a plan of safety and constant family observation will decrease the risk for self-harm.

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

ANS: 4 The client's statement "I don't drink too much!" alerts the nurse to the use of the defense mechanism of denial. The client is refusing to acknowledge the existence of a real situation and the feelings associated with it.

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

ANS: 4 The client's statements indicate the problem of hopelessness. Prior to assigning either risk for injury or risk for suicide, a further evaluation of the client's suicidal ideations and intent would be necessary.

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

ANS: 4 The nurse should assess that the client's daily functioning is not impaired. The client who experiences feelings of sadness after the loss of a pet is responding within normal expectations.

An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which ethical principle should a nurse determine has been violated based on these actions? 1. Autonomy 2. Beneficence 3. Nonmaleficence 4. Justice

ANS: 4 The nurse should determine that the ethical principle of justice has been violated by the physician's actions. The principle of justice requires that individuals should be treated equally, regardless of race, sex, marital status, medical diagnosis, social standing, economic level, or religious belief.

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

ANS: 4 The nurse's priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurse's priority.

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

ANS: 4 This statement verbalizes the client's implied feelings and allows him or her to validate and explore them. This statement also shows empathy toward the client and may help them open up and discuss their feelings.

A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, "I can't function any longer under all this stress." Which type of crisis is the client experiencing? 1. Maturational/developmental crisis 2. Psychiatric emergency crisis 3. Anticipated life transition crisis 4. Traumatic stress crisis

ANS:2 The nurse should determine that the client is experiencing a psychiatric emergency crisis. Psychiatric emergencies occur when crisis situations result in severe impairment, incompetence, or an inability to assume personal responsibility.