NCLEX - PassPoint PN

The nurse is caring for a client with a history of cocaine abuse. Which test might be ordered following a return to an inpatient treatment facility? antibody screen glucose screen hepatic screen urine screen

urine screen Explanation: A urine toxicology screen would show the presence of cocaine in the body. Antibody, glucose, or hepatic screening wouldn't show the presence of cocaine in the body.

A client with obesity is admitted to the hospital for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client? Identify alternative ways for the client to lose weight. Encourage the client to discuss the addiction. Empathize with the client's physical reports. Use an abrupt, firm manner with the client.

Identify alternative ways for the client to lose weight. Explanation: Identifying alternative ways to lose weight can help the obese client who abuses amphetamines to reach a weight loss goal safely. The nurse should encourage the client to express feelings, especially those related to obesity (e.g., concerns about control, which may be the root of the problem) and not focus on addiction. Empathizing with the client's physical reports may worsen them. Using an abrupt, firm manner discourages therapeutic communication with the obese client.

As the nurse helps a client to the bathroom, the client says, "When you get to the point where you can't even go to the bathroom by yourself, you might as well be dead." Which response by the nurse would be most therapeutic? "Keep your chin up. Things will look better tomorrow." "Why are you feeling so down today? This isn't like you." "You sound really discouraged today." "You're making great progress. A week ago, you couldn't even get out of bed."

"You sound really discouraged today." Explanation: Sharing an observation with the client conveys awareness of the client's feelings and promotes further communication. Spouting clichés, disagreeing with the client, or asking why the client feels a certain way doesn't promote therapeutic communication.

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

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

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

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

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

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

The nurse is gathering information on a client who appears to be anxious. Which is important for the nurse to remember when questioning the anxious client? be specific and direct avoid the client until the anxiety is gone avoid asking questions until the client talks about the subject be abstract and threatening

be specific and direct Explanation: Questions about the client's anxiety should be specific, direct, and individualized to the client. Abstract and threatening would be incorrect, because when a client is experiencing anxiety, abstract thinking is impaired. Both avoidance questions are incorrect because the nurse should ask direct and specific questions about the client's anxiety.

A client is diagnosed with illness anxiety disorder. When assisting with the plan of care, which intervention should be included? Confront the client with the statement, "It's all in your head." Help the client eliminate the stress in her life. Teach the client adaptive coping strategies. Encourage the client to focus on identification of physical symptoms.

Teach the client adaptive coping strategies. Explanation: Because of weak ego strength, a client with illness anxiety disorder is unable to use coping mechanisms effectively. The nursing focus is to teach adaptive coping mechanisms. It is not realistic to eliminate all stress. A client should never be confronted with the statement, "It's all in your head," because this would not facilitate a long-term therapeutic relationship, which is necessary to offer reassurance that no physical disease is present. The client is already aware of his physical symptoms and encouraging him to focus on them would not be therapeutic.

A client with colorectal cancer being prepared for colostomy placement tells the nurse, "I am very nervous and unsure about this surgery." What should the nurse's initial action be when caring for this client? Arrange for someone who has a colostomy to visit the client. Determine what the client already knows about colostomies. Show the client pictures of colostomies to prepare for the surgery. Provide the client with written materials about colostomy care.

Determine what the client already knows about colostomies. Explanation: Initially, the nurse should determine not only what the client already knows but also what the client wants to know. The nurse should evaluate the client's perceptions of how a colostomy will affect the client's lifestyle and sexuality. Providing written materials and pictures and arranging for a visit by someone who has an ostomy are all appropriate interventions when the client is ready to receive more detailed information.

A nurse is caring for a client with dissociative amnesia who is exhibiting signs of low self-esteem. The nurse determines that the interventions have been successful when the client demonstrates which behavior? greater time spent with the nurse participation in new activities inability to confront fear of failure sleeping without interruption at night

participation in new activities Explanation: Interventions for persons with dissociative amnesia and low self-esteem would be demonstrated by participation in new activities and the ability to confront the fear of failure. There is not an issue related to sleeping. Spending more time with the nurse would be inappropriate. The client needs to participate in new activities with others.

A client diagnosed with panic disorder and agoraphobia is talking with the nurse about the progress made in treatment. Which statement indicates a positive client response? "Last night I decided to eat more than a bowl of cereal." "Today I decided that I can stop taking my medication." "I went to the mall with my friend last Saturday." "I'm hyperventilating only when I have a panic attack."

"I went to the mall with my friend last Saturday." Explanation: Clients with panic disorder tend to be socially withdrawn. Going to the mall is a sign of working on avoidance behaviors. Hyperventilation is a key symptom of panic disorder. Teaching breathing control is a major intervention for clients with panic disorder. The client taking medications for panic disorder, such as tricyclic antidepressants and benzodiazepines, must be weaned off these drugs. Most clients with panic disorder and agoraphobia don't have nutritional problems.

A client confides to a nurse, "I have urges and desires to have sex with children." What should the nurse's most appropriate response be? Ask the client, "Have you ever acted on these desires?" Inform child protective services about the client and the thoughts the client reported. Explain that these thoughts are unacceptable and intensive therapy is need. Question the client, "Are you able to control your thoughts about sexual relations with children?"

Ask the client, "Have you ever acted on these desires?" Explanation: If a client reports a desire for pedophilia, then it is important to assess if the client ever acted upon these thoughts; the best predictor of future behaviors is past behaviors. Humans may have sexual fantasies but it is their behavior by which they are judged. No human thoughts are unacceptable, but therapy is required if the client is dystonic. Informing child protective services is premature; the nurse has not obtained information whether the client has acted on these thoughts.

A client is diagnosed with postpartum depression. The nurse is concerned because which outcome could be observed? It should self-correct without specific intervention. It is a strong indicator of spousal abuse by the father of the child toward the new mother. It signals inadequate maternal instincts in the mother. It may result in psychosis or infanticide.

It may result in psychosis or infanticide. Explanation: Undetected postpartum depression may lead to serious disturbances in mother-infant bonding, breastfeeding effectiveness, and family functioning. In rare circumstances postpartum depression may result in psychosis, infanticide, or both. Postpartum depression is a true form of depression that requires interventions. It does not indicate inadequate maternal instincts or spousal abuse.

A client who experienced alcohol withdrawal is no longer having hallucinations or tremors and states, "I would like to enter a rehabilitation facility to stop drinking." Which intervention is appropriate? Ask about insurance. Promote participation in a treatment program. Refer the client to Alcoholics Anonymous (AA). Have the client discuss this with family members.

Promote participation in a treatment program. Explanation: The client should be encouraged to enter a facility if that's in his best interest. Arrangements can be made and discussed with the social services coordinator and health care provider as well as having social services discuss insurance concerns. The client can inform the family, and support should be encouraged. Referral to AA should be considered after rehabilitation takes place.

A client is brought to the emergency department after being sexually assaulted by a rival gang member. The nurse observes that the client appears relaxed and is calmly talking to a relative. The nurse determines that the client may be using which defense mechanism? projection denial displacement rationalization

denial Explanation: The client is demonstrating the defense mechanism of denial, in which a client retreats inward to reduce the threat of what has happened to his or her self-concept. Rationalization prevents admitting an inadequacy. Displacement transfers feelings about one person to another. Projection places blame on someone else or on circumstances.

The nurse is caring for a client with generalized anxiety disorder (GAD). For which concurrent diagnosis should the nurse monitor the client? schizoaffective disorder bipolar disorder gender identity disorder panic disorder

panic disorder Explanation: Approximately 75% of clients with GAD may also have a diagnosis of phobia, panic disorder, or substance abuse. Clients with GAD do not tend to have a coexisting diagnosis of bipolar disorder, gender identity disorder, or schizoaffective disorder.

A client experiencing paranoid delusions states, "They are conspiring against me; they're after me all night." Which response by the nurse would be the most empathic? "This cannot be true." "You can't sleep?" "That sounds frightening." "You are having a delusion."

"That sounds frightening." Explanation: The most empathic response would be to acknowledge that the delusion sounds frightening. This response would address the client's feelings. The other three options do not address feelings or demonstrate that the nurse is caring.

A single parent of a school-age child recently diagnosed with a growth hormone deficiency comments that the prescribed treatment plan seems very complicated. What is the bestresponse from the nurse? "Don't worry, it will get easier with time." "I can teach you anything you need to know." "Everyone feels that way at first." "This must be a stressful time for you."

"This must be a stressful time for you." Explanation: The single parent appears to be overwhelmed trying to deal with the child's diagnosis and treatment plan. The best response is for the nurse to acknowledge the parent's stress. The other responses do not do that.

A client confides to a nurse, "I have urges and desires to have sex with children." What should the nurse's most appropriate response be? Explain that these thoughts are unacceptable and intensive therapy is need. Inform child protective services about the client and the thoughts the client reported. Question the client, "Are you able to control your thoughts about sexual relations with children?" Ask the client, "Have you ever acted on these desires?"

Ask the client, "Have you ever acted on these desires?" Explanation: If a client reports a desire for pedophilia, then it is important to assess if the client ever acted upon these thoughts; the best predictor of future behaviors is past behaviors. Humans may have sexual fantasies but it is their behavior by which they are judged. No human thoughts are unacceptable, but therapy is required if the client is dystonic. Informing child protective services is premature; the nurse has not obtained information whether the client has acted on these thoughts.

A 15-year-old client who sustained a spinal cord injury is on bedrest. Which intervention by the nurse might best help the adolescent cope with the prolonged bedrest? Providing the client with video games Allowing his parents unrestricted visiting Encouraging visitation by his friends Providing the client with reading material

Encouraging visitation by his friends Explanation: Encouraging visitation by friends might best help the adolescent cope with prolonged bedrest. Friends are much more important than family to this age-group. Providing reading material and video games might

A 52-year-old client admitted with a 3-month history of hemoptysis, shortness of breath, weight loss, and chronic productive cough undergoes testing, which reveals bronchial cancer. After being informed of his diagnosis, the client is tearful and nervous. He tells the nurse he has questions about the type of treatment plan an oncologist might offer. Which action should the nurse take? Discuss all of the latest treatment options with the client. Provide emotional support and explain that his course of treatment will most likely include chemotherapy. Offer emotional support and reassure the client that an oncologist is being consulted to devise a treatment plan. Explain to the client that he really needs to relax.

Offer emotional support and reassure the client that an oncologist is being consulted to devise a treatment plan. Explanation: The nurse should provide emotional support to the client and reassure him that an oncologist is being consulted to devise a treatment plan. It's beyond the scope of nursing practice to discuss the latest treatment options or say that chemotherapy is a likely treatment. Telling the client to relax is an unprofessional response that minimizes the client's anxiety and concerns.

A 40-year-old executive who was unexpectedly laid off from work 2 days ago reports fatigue and an inability to cope. He admits drinking excessively over the last 48 hours. This behavior is an example of which condition? A manic episode Depression Situational crisis Alcoholism

Situational crisis Explanation: A situational crisis results from a specific event in a person's life. The person is overwhelmed by the situation and reacts emotionally. Fatigue, insomnia, and inability to make decisions are common signs and symptoms. The situational crisis may precipitate behavior that causes a crisis (alcohol or drug abuse). There isn't enough information to label this client an alcoholic. A manic episode is characterized by euphoria and labile affect. Symptoms of depression are usually present for 2 or more weeks. This client's symptoms have been present for only 48 hours.

Which communication guideline should the nurse use when talking with a client experiencing mania? address the client in a light and joking manner focus and redirect the conversation as necessary ask open-ended questions to facilitate conversation allow the client to talk about several different topics

To decrease stimulation, the nurse should attempt to redirect and focus the conversation, not allow the client to talk about different topics. Addressing the client in a light and joking manner may contribute to the client feeling out of control. It's best to ask a manic client closed questions because open-ended questions enable him to talk endlessly, possibly contributing to the client feeling out of control.

A nurse is collecting data on an older adult client with ulcerative colitis. Which factor related to the family will have the greatest impact on the client's rehabilitation after discharge? understanding the ups and downs of the client's illness taking care of the client's special dietary needs providing emotional support to the client expecting the client to resume role-related activities

providing emotional support to the client Explanation: Emotional support from the family is the main need for an older adult client with ulcerative colitis. Providing a special diet does not fulfill the client's emotional needs. The family's role expectations do not address the client's emotional needs, but providing emotional support while the client is fulfilling these roles is important. The family's ability to understand the difficulties of the illness helps them but not the client.

The nurse is completing the admission assessment of a client in the labor and delivery area, when the client and her husband ask whether their sons, ages 8 and 10, can witness the childbirth. Which statement made by the nurse is accurate? "The children and client should share a support person during the childbirth." "Children shouldn't attend childbirth because it will frighten them." "Children should attend childbirth only if it takes place at home." "Each child attending the childbirth should have a separate support person."

"Each child attending the childbirth should have a separate support person." Explanation: Each child attending the childbirth should have a support person — one who isn't also serving as the client's support person. The support person explains what is happening, reassures the child, and removes the child from the area if an emergency occurs or if the child becomes frightened. Children can attend childbirth in any setting. The decision to have a child present hinges on the child's developmental level, ability to understand the experience, and amount of preparation.

A client signed herself into an alcohol treatment program. During the first visit with the nurse, she vehemently maintains there is no problem with alcohol and states that she is in the program only because the spouse issued an ultimatum. What is the best response by the nurse? "Because you came voluntarily, you're free to leave anytime you wish." "You sound pretty definite about not having a problem with alcohol." "I wonder why your spouse would issue such an ultimatum?" "From your point of view, what is most important for me to know about you?"

"From your point of view, what is most important for me to know about you?" Explanation: Asking the client what is most important for the nurse to know about her allows the nurse to collect more information. Wondering why the spouse would issue an ultimatum focuses on the spouse, not the client. Telling the client she is free to leave is abrasive and blocks communication. Telling the client that she sounds definite about not having an alcohol problem doesn't allow for further exploration of her problem.

A client was hospitalized after a family member filed a petition for involuntary hospitalization for safety reasons. The family member seeks out the nurse because the client is angry and refuses to talk. The family member states, "I feel so guilty about my decision." Which response by the nurse is the most empathic? "This is a stressful time for you, but you'll feel better when your family member gets well." "It's common for family members to feel this way. Can you tell me more?" "Your family member will feel differently about you when they get better." "Your family member is here because they need help."

"It's common for family members to feel this way. Can you tell me more?" Explanation: This response is most empathic because it focuses on the family member to help understand they are not alone. In addition, by asking the family to tell the nurse more about it helps to discuss and deal with feelings. Unresolved feelings of guilt, shame, isolation, and loss of hope impact the family's ability to manage the crisis and be supportive of the client. The other responses offer premature reassurance and cut off the opportunity for the family member to discuss feelings.

A client is scheduled for a surgical procedure for removal of a pancreatic tumor. The client states to the nurse, "I don't think I'll live through the surgery. I'm scared." What is the bestresponse by the nurse? "Let's talk about your concerns and fears." "Well, you might be right. Not everyone makes it through surgery." "When I had surgery, I felt the same way." "If you feel like this, you should say goodbye to your family."

"Let's talk about your concerns and fears." Explanation: The client is expressing concerns and fears related to having a serious surgical procedure; the most therapeutic response the nurse can give is to let the client know that she is not alone and someone is present to talk to about the feelings she is having. Telling the client that not everyone makes it through surgery does not address the client's fears and can make the anxiety about the procedure worse. Advising the client to say goodbye to her family also does not respond to the fears and lends finality to the situation. Discussing what the nurse felt when having surgery does not address the client's concern.

A client has just been diagnosed with terminal cancer and is being transferred to home hospice care. The client's child tells the nurse, "I don't know what to say to my mother if she asks me about dying." Which responses by the nurse would be appropriate? Select all that apply. "Let's talk about your mother's illness and how it will progress." "You sound like you have some questions about your mother dying. Let's talk about that." "Don't worry, hospice will take care of your mother." "Tell me how you're feeling about your mother dying." "Don't worry. Your mother still has some time left."

"Let's talk about your mother's illness and how it will progress." "You sound like you have some questions about your mother dying. Let's talk about that." "Tell me how you're feeling about your mother dying." Explanation: Conveying information and providing clear communication can alleviate fears and strengthen the individual's sense of control. Encouraging verbalization of feelings helps build a therapeutic relationship based on trust and reduces anxiety. Telling the client's child not to worry disregards feelings and discourages further communication.

A client with gradually occurring global impairments of cognitive functioning, memory, and personality is most likely to have: age-related cognitive decline. body dysmorphic disorder. Alzheimer's-type dementia. tardive dyskinesia.

Alzheimer's-type dementia. Explanation: A client with Alzheimer's-type dementia suffers gradual global impairment of cognitive functioning, memory, and personality. Age-related cognitive decline refers to an objectively identified decrease in cognitive functioning related to aging that's within normal limits and not attributable to a specific mental disorder or neurologic condition. In body dysmorphic disorder, the client is preoccupied with an imagined or slight defect in his physical appearance. Tardive dyskinesia is an adverse effect that may occur with certain psychotropic drugs. The client displays slow, rhythmic movements that are generalized or occur in certain muscle groups.

A client chronically complains of being unappreciated and misunderstood by others. She is argumentative and sullen. She always blames others for her failure to complete work assignments. She expresses feelings of envy toward people she perceives as more fortunate. She voices exaggerated complaints of personal misfortune. The client most likely suffers from which personality disorder? Avoidant personality disorder Dependent personality Obsessive-compulsive disorder Passive-aggressive personality

Passive-aggressive personality Explanation: The client with passive-aggressive personality disorder displays a pervasive pattern of negative attitudes, chronic complaints, and passive resistance to demands for adequate social and occupational performance. Regarding the other answer options, the client with a dependent personality is unable to make everyday decisions and allows others to make important decisions; in addition, he often volunteers to do things that are unpleasant so that others will like him. The obsessive-compulsive personality displays perfectionism and inflexibility. The avoidant personality displays a pervasive pattern of social discomfort, fear of negative evaluation, and timidity.

A nurse is caring for a 17-year-old brought to the mental health facility by a family member who is concerned about the client's recent 20-lb (9 kg) weight loss, and weight loss total of 50 lb (22.7 kg) in the last year. What interventions are essential in the treatment of an adolescent diagnosed with an eating disorder? Select all that apply. Provide an isolation environment to monitor all activities. Instruct the client and family that treatment for eating disorders takes a few weeks and the family is not involved in the process. Monitor the clients' weight, vitals, intake and output, caloric intake, and exercise. Assist the client in changing the negative perception to a positive one, and assist in setting realistic goals. Provide a highly structured environment.

Provide a highly structured environment. Monitor the clients' weight, vitals, intake and output, caloric intake, and exercise. Assist the client in changing the negative perception to a positive one, and assist in setting realistic goals. Explanation: Mental health nursing care measures are essential in the treatment of an adolescent diagnosed with an eating disorder. Care measures include providing a highly structured environment; involving client in decision making and participation in the plan of care; assisting the client in setting realistic goals; promoting cognitive reframing; assisting the client in changing the negative perception to a positive one; and monitoring the client's weight, vitals, intake, and output, caloric intake, and exercise. Clients should not be isolated unless they are in danger of harming themselves or others. It is important to instruct families that treatment for eating disorders can take a long time, and family members will be involved in the recovery.

A nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. What action should the nurse take to assist the client with coping? Provide a referral to the Cancer Society or another support program. Encourage the client to proceed with the next phase of treatment. Tell the client's spouse or partner to be supportive while she recovers. Recommend that the client remain cheerful for the sake of her children.

Provide a referral to the Cancer Society or another support program. Explanation: If the client who has just had a modified radical mastectomy with immediate reconstruction is not withdrawn and does not show other signs of anxiety or depression, the nurse can approach her about talking with others who have had similar experiences, either through The Cancer Society or through another formal support group. The nurse may educate the client's spouse or partner and listen to concerns but should not tell the client's spouse what to do. The client must consult with her primary care provider and make her own decisions about further treatment. The client needs to express any sadness, frustration, and fear, and the nurse should encourage the client to do so.

The mother of a 3-year-old child is complaining that her son still throws temper tantrums when he doesn't get his way. How should the nurse advise the mother to respond? Tell the mother to give in to his demands; he is only 3-years-old. Tell the mother to mimic him so that he can see what his behavior looks like. Tell the mother to promise him a new toy if he stops the tantrum. Tell the mother to ignore the child because eventually he will stop having temper tantrums.

Tell the mother to ignore the child because eventually he will stop having temper tantrums. Explanation: This child is in Erikson's developmental stage of initiative versus guilt. Guilt develops when the child is made to feel bad about his behavior. Ignoring the negative behavior shows the child that he'll gain nothing through negative behavior such as temper tantrums. Promising the child a new toy or giving in to his demands will reinforce his negative behavior by rewarding his tantrums. Mimicking the child will make him feel guilty.

The home health nurse is completing the admission paperwork for a new client diagnosed with osteomyelitis who will be receiving home service intravenous therapy for the next month. The client is 32 years old and happily married. Which of the following findings will warrant further investigation? Select all that apply. The client voices concerns about recovering quickly so that she might return back to work in the next month. The client reports having many hobbies and interests outside of the home. The client is talkative about her spouse and children. The client spends a great deal of time reflecting back on her teen years. The client talks repeatedly about her death.

The client talks repeatedly about her death. The client spends a great deal of time reflecting back on her teen years. Explanation: At age 32, the client is in the middle adult stage of life. Her repeated discussions about death and reflections back on life aren't appropriate or expected for this stage of development and should be investigated further. An interest in civic responsibilities and the establishment of hobbies is expected. During this developmental period, the greatest concern typically relates to establishing gainful employment and significant relationships. This is being demonstrated by the client's willingness to discuss her spouse and children.

A client with paranoid personality disorder responds aggressively to something another client said during a psychoeducational group session. Which rationale explains the likely underlying cause of the client's response to the interaction? The client doesn't want to participate in the group. The client took the statement as a personal criticism. The client was attempting to handle emotional distress. The client is impulsive and was acting out frustrations.

The client took the statement as a personal criticism. Explanation: Clients with paranoid personality disorder tend to be hypersensitive and take what other people say as a personal attack on their character. The client's participation in group therapy would be minimal because the client is directing energy toward emotional self-protection. Clients with a paranoid personality disorder tend to be rigid and guarded rather than impulsive and rebellious. The client with a paranoid personality disorder is acting to defend himself, not handle emotional distress.

A client is admitted to the psychiatric unit with a history of obsession regarding weight, bingeing, and purging after eating. The client's weight has been stable at 96 lb (43.5 kg) and determined to be normal for height. The nurse reviews these findings with the understanding that they may be most likely associated with which disorder? anorexia nervosa bulimia Kleine-Levin syndrome dysthymia

bulimia Explanation: Although bulimia and anorexia nervosa both involve excessive concern with body weight, this client's bingeing and purging of food is typical of bulimia. So too is the weight which is normal for the height. Anorexia nervosa involves severe weight loss and vomiting after eating. Kleine-Levin syndrome includes symptoms of disturbed eating behavior, but the condition is not characterized by an excessive concern with body weight and shape. Dysthymia is a type of depression.

A client with antisocial personality disorder smokes where it's prohibited and refuses to follow other unit and facility rules. The client gets others to do his laundry and other personal chores, splits the staff, and will work only with certain nurses. The plan of care for this client should focus primarily on: isolating the client to decrease contact with easily manipulated clients. using behavior modification to decrease negative behavior by using negative reinforcement. consistently enforcing unit rules and facility policy. engaging in power struggles with the client to minimize manipulative behavior.

consistently enforcing unit rules and facility policy. Explanation: Firmness and consistency regarding rules are the hallmarks of a plan of care for a client with a personality disorder. Isolation is inappropriate and violates the client's rights. Power struggles should be avoided because the client may try to manipulate people. Behavior modification usually fails because of staff inconsistency and client manipulation.

An obese client is admitted to the facility for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client? encouraging the client to suppress his or her feelings regarding obesity teaching the client alternative ways to lose weight using an abrupt, forceful manner to communicate with the client reinforcing the client's concerns over physical appearance

teaching the client alternative ways to lose weight Explanation: Teaching the client alternative ways to lose weight is the appropriate intervention. Instead of encouraging the client to suppress his or her feelings, the nurse should encourage the client to express feelings, especially those related to obesity. Reinforcing the client's concerns about physical appearance may make the client's anxiety worse and lead to more self-destructive behavior. Using an abrupt, forceful manner discourages therapeutic communication with the client.

A client with schizophrenia is admitted to the psychiatric unit of a hospital. Data collection should include careful observation of the client's: psychomotor activity. thinking, perceiving, and decision-making skills. verbal and nonverbal communication processes. affect and behavior.

thinking, perceiving, and decision-making skills. Explanation: Data collection of a psychotic client should include careful inquiry about and observation of the client's thinking, perceiving, symbolizing, and decision-making skills and abilities. Assessment of such a client typically reveals alterations in thought content and process, perception, affect, and psychomotor behavior; changes in personality, coping, and sense of self; lack of self-motivation; presence of psychosocial stressors; and degeneration of adaptive functioning. Although assessing communication processes, affect, behavior, and psychomotor activity would reveal important information about the client's condition, the nurse should concentrate on determining whether the client is hallucinating by assessing thought processes and decision-making ability.

The etiology of schizophrenia is best described by: genetics due to a faulty dopamine receptor. a combination of biological, psychological, and environmental factors. structural and neurobiological factors. environmental factors and poor parenting.

Teach the client adaptive coping strategies. Explanation: Because of weak ego strength, a client with illness anxiety disorder is unable to use coping mechanisms effectively. The nursing focus is to teach adaptive coping mechanisms. It is not realistic to eliminate all stress. A client should never be confronted with the statement, "It's all in your head," because this would not facilitate a long-term therapeutic relationship, which is necessary to offer reassurance that no physical disease is present. The client is already aware of his physical symptoms and encouraging him to focus on them would not be therapeutic.

The client is scheduled for extracorporeal shock wave lithotripsy (ESWL). The nurse should reinforce that the stones will be what? diffused suctioned shattered radiated

shattered Explanation: ESWL is a procedure in which the client's kidney stones are shattered or pulverized, not radiated, suctioned, or diffused.

A client taking antidepressants for major depression for about 3 weeks now states " I'm feeling better." Which complication should the client be monitored for? suicidal ideation potential for violence substance abuse manic depression

suicidal ideation Explanation: After a client has been on antidepressants and is feeling better, he commonly then has the energy for self-harm. Manic depression isn't treated with antidepressants. Nothing in the client's history suggests a potential for violence. There are no signs or symptoms suggesting substance abuse.

Which clinical characteristic affects client compliance? Disease duration and severity The nurse-client relationship Psychosocial factors Drug knowledge

The nurse-client relationship Explanation: Two major clinical characteristics affect client compliance: the nurse-client relationship and the therapeutic regimen. The client's drug knowledge, psychosocial factors, and disease duration and severity are client characteristics, not clinical ones.

A client recently diagnosed with colon cancer states, "I am having trouble sleeping because of thoughts of how life will change after surgery." What is the best response by the nurse? "I will talk to the charge nurse about this." "I will sit and talk with you about how you are feeling." "I will request a chaplain to come and talk with you." "I will refer you to a cancer support group."

"I will sit and talk with you about how you are feeling." Explanation: The client is having trouble sleeping because of concerns about life changes. The client may be experiencing anxiety and powerlessness. Encouraging the client to verbalize feelings will help the nurse to determine how to assist the client and may reduce the client's anxiety. The other options do not directly address the client's comments and concerns.

The parents of a 9-year-old child in the terminal phase of a fatal illness ask the nurse for guidance in discussing death with their child. Which response is appropriate? "Children of that age typically fantasize about what dying will be like, which is much better than knowing the truth." "Children of that age view death as temporary and reversible, which makes it hard to explain." "At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it." "At this developmental stage, children are afraid of death, so it's best not to discuss it with them."

"At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it." Explanation: By age 9 or 10, most children have an adult concept of death. Caregivers should discuss death with them in terms consistent with their developmental stage. School-age children respond well to concrete explanations about death and dying. Preschoolers, not school-age children, typically view death as temporary and reversible. School-age children may fantasize about the unknown aspects of death; these fantasies may increase their anxiety. Although a child may fear death, accurate information about death can ease anxiety.

A client requested a do-not-resuscitate (DNR) order upon admission to the hospital and later tells the nurse, "I want to have everything possible done to help me get better." Which response by the nurse would be most appropriate? "It's too late to change your mind now." "We'll have to ask your health care provider if the DNR can be changed." "It isn't a problem to rescind your DNR order. "You should talk with your family before making this decision."

"It isn't a problem to rescind your DNR order. Explanation: A client is allowed to rescind a DNR order at any time. The client can make a decision about a DNR order without input from the health care provider or family members. A nurse should not question a client's motives in rescinding the DNR order; that could make the client feel defensive and shut down communication with the nurse.

A pregnant client in the first trimester comes to the clinic. During the visit, the client says, "My husband is so excited, but I'm worried because I'm not feeling the same way. Does this mean that I will be a bad mother?" Which response by the nurse would be most appropriate? "It's best to talk this over with your husband so he can help you out when the baby comes." "Maybe you should try discussing your feelings with someone who is emotionally close to you." "What you're feeling right now is entirely normal for where you are at this stage." "You are right to be concerned. Let's see if we can get you some counseling."

"What you're feeling right now is entirely normal for where you are at this stage." Explanation: Misgivings and fears, including ambivalence or the lack of excitement are common in the beginning of pregnancy. The client needs to know that her feelings are entirely normal. These feelings do not necessarily mean that the client requires counseling at this time. The client may benefit by discussing her feelings with her husband or someone else she is close to, but it is more important for the nurse to communicate to the client that her feelings are normal.

The nurse educator is presenting an in-service on unhealthy boundaries. The educator will discuss how unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models. Which factor should the educator include that indicates unhealthy boundaries may also be a result of? Structured limit-setting Supportive environment Direction and attention Abuse and neglect

Abuse and neglect Explanation: Abuse and neglect lead to poor self-concept and role confusion, the basis for unhealthy personal boundaries. Healthy boundaries are established in childhood when parents provide consistent, supportive limits and attention.

An adolescent who is depressed and whose parents report as having difficulty in school is brought to the community mental health center to be evaluated. Which additional problem would the nurse expect the client to have? Anxiety disorder Behavioral difficulties Labile moods Cognitive impairment

Behavioral difficulties Explanation: Adolescents with depression tend to demonstrate severe irritability and behavioral problems. Anxiety disorder is more commonly associated with small children. Cognitive impairment is typically associated with delirium and dementia. Labile mood is more characteristic of a client with bipolar disorder.

A woman is admitted to the psychiatric emergency department. Her significant other reports that she has difficulty sleeping, has poor judgment, and is incoherent at times. The client's speech is rapid and loose. She has a history of depressed mood for which she has been taking an antidepressant. The nurse suspects which diagnosis? Somatic symptom disorder Paranoid personality Obsessive-compulsive disorder (OCD) Bipolar illness

Bipolar illness Explanation: Bipolar illness is characterized by mood swings from profound depression to elation and euphoria. Delusions of grandeur along with pressured speech are common symptoms of mania. Paranoia is characterized by unrealistic suspiciousness and is often accompanied by grandiosity. OCD is a preoccupation with rituals and rules. Somatic symptom disorder is characterized by multiple physical symptoms that develop during times of emotional distress.

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

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

A client is diagnosed with obsessive-compulsive disorder. Which intervention should the nurse include when assisting with development of the plan of care? Preventing ritualistic behavior Increasing environmental stimulation Giving the client adequate time to perform rituals Setting strict limits on compulsive behavior

Giving the client adequate time to perform rituals Explanation: The nurse should give the client adequate time to perform rituals because this reduces anxiety. The other options would increase the client's anxiety.

A nurse is reinforcing education for a client on how to perform tracheostomy care. What is the most important principle of client education that the nurse needs to utilize? Determine the client's readiness to learn new information. Build on previous information that the client understands. Provide the most up-to-date information available. Alleviate the client's guilt of not knowing the appropriate self-care.

Determine the client's readiness to learn new information. Explanation: Client readiness is critical to accepting and integrating new information. Unless the client is ready to accept new information, teaching will be ineffective. Providing up-to-date information does not matter if the client is not ready to accept new information. Client guilt cannot be alleviated until the client understands the intricacies of the condition and the physiologic response to the disease. If the client is not ready to learn, building on previous information will be impossible because the client will not be receptive to the education.

A child is admitted with a tentative diagnosis of clinical depression. Which data collection finding is most significant in confirming this diagnosis? Irritability Weight gain Fatigue Sadness

Sadness Explanation: Clinical depression is diagnosed if the child exhibits a depressed mood (sadness) or loss of interest. Irritability isn't diagnostic for depression in children. Although a depressed child may gain weight and report fatigue, these findings aren't essential to the diagnosis.

A client with dependent personality disorder is working on goals for self-care. Which short-term goal statement would be the initial goal? determine activities that can be performed without help write a daily schedule for each day of the week complete self-care activities in a minimal amount of time perform all self-care activities independently

determine activities that can be performed without help Explanation: Each of the statements would be appropriate for inclusion in the plan of care. The initial goal, however, will be the determination of activities. The other goal statements may be included but not first. By determining activities that can be performed without assistance, the client with dependent personality disorder can then begin to practice them independently. If the nurse only encourages a client to perform self-care activities independently, nothing may change. Writing a daily schedule doesn't help the client focus on what needs to be done to promote self-care. The amount of time needed to perform self-care activities isn't important. If time pressure is put on the client, there may be more reluctance to perform self-care activities.

In group therapy, a client angrily speaks up and responds to a peer, "You're always whining, and I'm getting tired of listening to you! Here is the world's smallest violin playing for you." Which of the following roles is the client playing? Aggressor Monopolizer Blocker Recognition seeker

Aggressor Explanation: The aggressor is negative and hostile and uses sarcasm to degrade others. The role of the blocker is to resist group efforts. The monopolizer controls the group by dominating conversations. The recognition seeker talks about accomplishments to gain attention.

A young adult client received her first chemotherapy treatment for breast cancer. Which statement by the client requires further exploration by the nurse? "I'm thinking about joining a dance club." "I don't think I'm going to work tomorrow." "I want to return to school for a college degree." "I don't care about the adverse effects of the drugs."

"I don't care about the adverse effects of the drugs." Explanation: Adverse effects of chemotherapy may occur after treatment and should be discussed with the client, because some can be treated, controlled, or prevented. The nurse needs to explore the client's meaning when she indicates apathy about the adverse effects of chemotherapy drugs. The client may feel poorly after chemotherapy and may want to take time off from work until she feels better. Joining social clubs and returning to school are typical behaviors for a young adult.

The nurse assisted in the education of a group of adolescent females about eating disorders. Which comments made by some of the teenagers would indicate to the nurse that the teaching was effective? Select all that apply. "Sometimes the pain with purging makes you feel as if you are having a heart attack." "Purging may cause tooth decay." "The doctor can give you medications to stop the vomiting if you have bulimia." "Eating disorders start around 13 years of age." "You can develop vitamin deficiency with anorexia."

"Purging may cause tooth decay." "You can develop vitamin deficiency with anorexia." Explanation: Because of exposure to gastric acid during purge, the client may develop tooth decay. The body does not store water vitamins; the anorexic client usually does not eat a well-balanced meal and may develop vitamin deficiency. Eating disorders usually occurs in female adolescents, but can occur at any age. Purging may be uncomfortable but does not feel as if the person is having a heart attack. The bulimic client needs psychotherapy, not antiemetics, to prevent vomiting.

Which statement, made by a client with paranoid personality disorder, shows that education about social relationships is effective? "I don't have problems in social relationships; I never really did." "As long as I live, I won't abide by social rules." "I'll find out what problems others have so I won't repeat them." "Sometimes I can see what causes relationship problems."

"Sometimes I can see what causes relationship problems." Explanation: Progress is shown when the client addresses behaviors that negatively affect relationships. Clients with paranoid personality disorder struggle to understand and express their feelings about social rules. Knowing other people's problems isn't useful; the client must focus on his own issues. Clients with paranoid personality disorder tend to have impaired social relationships and are very uncomfortable in social settings. By not recognizing the problem, the client indicates that he is in denial.

A client diagnosed with Alzheimer's disease (AD) tells the nurse that today a visitor is coming to have lunch. The nurse knows that the visitor isn't coming that day. Which response by the nurse would be most appropriate for this situation? "I think you need some more medication, and I'll bring it to you." "You're confused and don't know what you're saying." "Where are you planning to have your lunch?" "Today is Monday, March 8, and we'll be eating lunch in the dining room."

"Today is Monday, March 8, and we'll be eating lunch in the dining room." Explanation: The best nursing response is to reorient the client to the date and environment. Confrontation can provoke an outburst. Medication won't provide immediate relief for memory impairment.

A prenatal client says she can't believe she has such mixed feelings about being pregnant. She tried for 10 years to become pregnant and now feels guilty for her conflicting reactions. Which response by the nurse is best? "Let's make an appointment with a counselor." "You're experiencing the normal ambivalence pregnant mothers feel." "These feelings are expected only in women who have had difficulty becoming pregnant." "You need to talk to your midwife about these feelings."

"You're experiencing the normal ambivalence pregnant mothers feel." Explanation: Conflicting, ambivalent feelings regarding pregnancy are normal for pregnant women. These feelings don't call for counseling or other professional interventions. Ambivalence is felt by most pregnant women, not exclusively mothers who had difficulty becoming pregnant.

A client is being treated for alcoholism. After a family meeting, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. Which appropriate organization should the nurse suggest that the family joins? Emotions Anonymous Al-Anon Alcoholics Anonymous Make Today Count

Al-Anon Explanation: Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism. Make Today Count is a support group for people with life-threatening or chronic illnesses. Emotions Anonymous is a support group for people experiencing depression, anxiety, or similar conditions. Alcoholics Anonymous is an organization that helps alcoholics recover by using a 12-step program.

A licensed practical nurse is attending an in-service program about postpartum affective disorders. The LPN demonstrates understanding of the information by identifying that which percentage of postpartum clients experience "postpartum blues"? 80% 90% 20% 30%

80% Explanation: "Postpartum blues"—a transient mood alteration that arises during the first 3 weeks postpartum and is typically self-limiting—affects up to 80% of postpartum clients. A more severe mood alteration, postpartum depression, is seen in approximately 20% of clients and involves changes that occur within a few days after birth and may last for a few days to more than a year.

A client is brought to the facility in an agitated state and is admitted to the psychiatric unit for observation and treatment. While putting personal items away, the client talks rapidly and folds and unfolds garments several times. The client can't seem to settle down. Which nursing diagnosis is most applicable at this time? Impaired verbal communication Anxiety Impaired adjustment Powerlessness

Anxiety Explanation: Anxiety is the most applicable nursing diagnosis at this time because the client's behavior mimics some of the objective signs of anxiety, which include restlessness, irritability, rapid speech, inability to complete tasks, and verbal expressions of tension. The other options would be premature diagnoses because the nurse hasn't had an opportunity to complete a thorough nursing assessment.

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

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

Which short-term goal is appropriate for a client with borderline personality disorder who displays low self-esteem? stop obsessive-compulsive behaviors express fears and feelings decrease dysfunctional family conflicts write in a journal daily

express fears and feelings Explanation: Acknowledging fears and feelings can help the client identify parts of himself that make him uncomfortable, and he can begin to work on developing a positive sense of self. Writing in a daily journal isn't a short-term goal to enhance self-esteem. A client with borderline personality disorder doesn't struggle with obsessive-compulsive behaviors. Decreasing dysfunctional family conflicts is a long-term goal.

A nurse is using drawing, puppetry, and other forms of play therapy while caring for a terminally ill, school-age child. What is the primary nursing goal of play therapy for this child? acceptance of responsibility for the illness experiencing a good time while hospitalized internalization of feelings about death and dying expression of feelings that the child cannot articulate

expression of feelings that the child cannot articulate Explanation: Children may not have the verbal and cognitive skills to express what they feel and may benefit from alternative modes of expression such as drawing, puppetry, and other forms of play therapy. It is important for the child to find a way to express internalized feelings. The child must also know that he is not to blame for the situation. In the process of play therapy, the child can also have fun, but that is not the main goal of therapy.

A client with anorexia nervosa tells a nurse, "I'll never have the slender body I want." Which intervention is best to handle this problem? Develop an exercise program the client can participate in twice per week. Help the client work on developing a realistic body image. Call a family meeting to get help from the parents. Make an appointment for the client to see the dietitian on a weekly basis.

Help the client work on developing a realistic body image. Explanation: The client with anorexia nervosa pursues thinness and has a distorted view of self. A family meeting may not help the client develop a more realistic view of the client's body. Although meeting with a dietitian might be helpful, it isn't a priority. Clients with anorexia nervosa typically exercise excessively.

A client who experienced alcohol withdrawal is no longer having hallucinations or tremors and states, "I would like to enter a rehabilitation facility to stop drinking." Which intervention is appropriate? Ask about insurance. Have the client discuss this with family members. Refer the client to Alcoholics Anonymous (AA). Promote participation in a treatment program.

Promote participation in a treatment program. Explanation: The client should be encouraged to enter a facility if that's in his best interest. Arrangements can be made and discussed with the social services coordinator and health care provider as well as having social services discuss insurance concerns. The client can inform the family, and support should be encouraged. Referral to AA should be considered after rehabilitation takes place.

The nurse is assigned to care for a client with anorexia nervosa. Initially, which most appropriate nursing intervention would the nurse implement for this client? Providing one-on-one supervision during meals and for 1 hour afterward Letting the client eat with other clients to create a normal mealtime atmosphere Trying to persuade the client to eat and thus restore nutritional balance Giving the client as much time to eat as desired

Providing one-on-one supervision during meals and for 1 hour afterward Explanation: Because the client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 hour afterward. Option 2 wouldn't be therapeutic because other clients may urge the client to eat and give attention for not eating. Option 3 would reinforce control issues, which are central to this client's underlying psychological problem. Instead of giving the client unlimited time to eat, as in option 4, the nurse should set limits and let the client know what is expected.

During a conversation with a client, the nurse recognizes a delusion of persecution. What is the priority action by the nurse? Redirect the conversation back to reality. Argue with the client over the reality of the delusion. Engage the client and enter into the delusion. Ask the client to expand on the comment.

Redirect the conversation back to reality. Explanation: The priority action is for the nurse to redirect the conversation back to reality. The nurse should never ask the client to expand on the comment, enter into the delusion, or argue with the client over the reality of the delusion.

The nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She's in her 30s and has two young children. Although she's worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping? Encourage the client to proceed with the next phase of treatment. Recommend that the client remain cheerful for the sake of her children. Tell the client's spouse or partner to be supportive while she recovers. Refer the client to the American Cancer Society's (Canadian Cancer Society's) Reach for Recovery program or another support program.

Refer the client to the American Cancer Society's (Canadian Cancer Society's) Reach for Recovery program or another support program. Explanation: The client isn't withdrawn and doesn't show other signs of anxiety or depression. Therefore, the nurse can probably safely approach her about talking with others who have had similar experiences, either through Reach for Recovery or another formal support group. The nurse may educate the client's spouse or partner and listen to his concerns, but the nurse shouldn't tell the client's spouse what to do. The client must consult with her physician and make her own decisions about further treatment. The client needs to express her sadness, frustration, and fear. She can't be expected to be cheerful at all times.

A client lives with a parent and the client's three children. Which type of family does this describe? extended dysfunctional blended nuclear

extended Explanation: An extended family consists of the biological or adoptive parents and one or more grandparents or other family members living together. A nuclear family consists of a husband, wife, and children. A dysfunctional family is one that demonstrates unhealthy relationship problems among family members. A blended family is one in which children from previous marriages live together.

A client in the manic phase of bipolar disorder constantly belittles other clients and demands special favors from the nurses. Which nursing intervention would be most appropriate for this client? Ask other clients and staff members to ignore the client's behavior. Distract the client with a variety of stimulating activities when negative behaviors occur. Set limits, with clear and consistent consequences, for behavior. Offer the client an antianxiety drug when he is belittling others or demanding special treatment.

Set limits, with clear and consistent consequences, for behavior. Explanation: To protect others from a client who exhibits belittling and demanding behaviors, the nurse needs to set limits with clear and consistent consequences for noncompliance. Asking others to ignore the client is likely to increase the denigrating behaviors. Offering the client an antianxiety drug or stimulating activities provides no motivation for the client to change problematic behaviors.

A nurse approaches a client who recently had a colostomy and finds the client crying. Which action is appropriate? Leave and come back another time. Sit down with the client and offer to talk about anything. Tell the client vital signs need to be obtained. Ask the client if there is pain or discomfort.

Sit down with the client and offer to talk about anything. Explanation: Asking open-ended questions and appearing interested in what the client has to say will encourage verbalization of feelings. Leaving the client may cause feelings of unacceptance. Asking closed-ended questions won't encourage verbalization of feelings. Ignoring the client's present state isn't therapeutic for the client.

A client is 2 months pregnant. Which factor should the nurse anticipate as most likely to affect her psychosocial transition during pregnancy? Previous experiences with health care facilities Previous health promotion activities Socioeconomic status Support from her partner

Support from her partner Explanation: Many factors can influence the smoothness of a pregnant client's psychosocial transition. The most important factors are support from her partner, parents, friends, and others; whether the pregnancy was planned or unplanned; and previous childbirth and parenting experiences. Age, socioeconomic status, sexuality concerns, birth stories of family members and friends, and past experiences with health care facilities and professionals may also influence a client's psychosocial transition during pregnancy, but these aren't the most important factors. Previous health promotion activities are least likely to affect this transition.

The nurse is collecting data from a parent regarding the child's behavior. Which behavior is consistent with the diagnosis of conduct disorder in this child? The child is wetting the bed at night. The child has purposely hurt animals. The child has threatened suicide. The child has a fear of attending school.

The child has purposely hurt animals. Explanation: Cruelty to animals is a symptom of conduct disorder. Enuresis and suicidal ideation aren't usually associated with conduct disorder. Fear of going to school is school phobia.

The nurse is caring for a client diagnosed with diabetes mellitus. When collecting data from this client, what finding best indicates the client is not coping with the disease? The client demonstrates a recent weight gain of 2 lb (0.9 kg) over 1 month. The client cries whenever diabetes is mentioned. The client is monitoring blood glucose levels. The client omits the insulin dose if a meal is missed.

The client cries whenever diabetes is mentioned. Explanation: A client who cries whenever diabetes is mentioned is demonstrating ineffective coping. A recent weight gain of 2 pounds (0.9 kg in a month is not significant and does not indicate that the client is not coping with a new disease process. Monitoring glucose levels and omitting a dose of insulin if a meal is missed demonstrates that the client is aware of the complications of the disease.

A nurse determines that a client with antisocial personality disorder is beginning to practice several socially acceptable behaviors in the group setting. Which behavior observed by the nurse would indicate this is taking place? fewer panic attacks acceptance of reality improved self-esteem decreased physical symptoms

improved self-esteem Explanation: When clients with antisocial personality disorder begin to practice socially acceptable behaviors, they also commonly experience a more positive sense of self. Clients with antisocial personality disorder don't tend to have panic attacks, alteration in their perception of reality, or somatic manifestations of their illness.

The nurse is assisting with a plan of care for a client in the behavioral health unit with antisocial personality disorder. What goal would be appropriate for this client? The family must assist the client to decrease ritualistic behavior. The family must start to use negative reinforcement of the client's behavior. The family must stop reinforcing inappropriate negative behavior. The family must learn to live with the client's impulsive behavior.

The family must stop reinforcing inappropriate negative behavior. Explanation: The family needs help learning how to stop reinforcing inappropriate client behavior. Clients with antisocial personality disorder don't show ritualistic behaviors. The family can set limits and reinforce consequences when the client shows impulsive behavior. Negative reinforcement is an inappropriate strategy for the family to use to support this client.

The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which trait would the nurse be likely to uncover during data collection? a low tolerance for frustration frequent expression of guilt about behavior history of gainful employment maintenance of close, stable relationships

a low tolerance for frustration Explanation: Clients with antisocial personality disorder exhibit a low tolerance for frustration, emotional immaturity, and a lack of impulse control. They commonly have a history of unemployment, miss work repeatedly, and quit work without other plans for employment. Typically, they do not experience guilt about their behavior and commonly perceive themselves as victims. They also display a lack of responsibility for the outcome of their actions. Because of a lack of trust in others, clients with antisocial personality disorder commonly have difficulty developing stable, close relationships.

The nurse is caring for a client with a white blood cell (WBC) count of 4000 mm3. While preparing the client for discharge, the nurse should reinforce that the client should avoid contact with which person? adult exposed to tuberculosis (TB) as a child child recently exposed to varicella pregnant female adult with human immunodeficiency virus (HIV)

child recently exposed to varicella Explanation: A child recently exposed to varicella could be contagious now. An adult exposed to TB has no indication of disease. Unless currently infected with another communicable disease, the adult with HIV and the pregnant female do not pose risks.

A hospitalized client who cares for a parent with Alzheimer's disease at home reports feeling guilty because, at times, the client wishes the parent would die. When talking with the client, which response would be most appropriate? "Everyone in your situation must feel like that at times." "Being responsible for your father's care must be difficult." "Perhaps you should consider putting your father in a nursing home." "There is no reason to feel guilty. You've given your father excellent care."

"Being responsible for your father's care must be difficult." Explanation: Acknowledging the difficulty inherent in caring for a parent with Alzheimer's disease directly addresses the client's feelings and encourages discussion about them. Telling the client that everyone in this situation feels similarly is a cliché and does not consider this particular client's situation. Suggesting a nursing home for the client's parent may increase the client's guilt. Dismissing the client's feelings of guilt suggests that the client's feelings are not valid.

One day after being admitted with bipolar disorder, a client becomes verbally aggressive during a group therapy session. Which response by the nurse would be therapeutic? "If you continue to talk like that, no one will want to be around you." "You're behaving in an unacceptable manner, and you need to control yourself." "You're disturbing the other clients. I'll walk with you around the patio to help you release some of your energy." "You're scaring everyone in the group. Leave the room immediately."

"You're disturbing the other clients. I'll walk with you around the patio to help you release some of your energy." Explanation: This response shows that the nurse finds the client's behavior unacceptable, yet still regards the client as worthy of help. The other options give the false impression that the client is in control of the behavior; the client hasn't been in treatment long enough to control the behavior.

A client who retired six weeks ago, has been diagnosed with an adjustment disorder with mixed anxiety and depression. What can the nurse reinforce to help the client adapt well to the stress? Select all that apply. Avoid social supports, such as friends and loved ones. Remain hopeful about the past. Do something that gives you a sense of accomplishment. Find a support group geared toward your situation. Live a healthy lifestyle including a healthy diet and regular physical activity.

Do something that gives you a sense of accomplishment. Find a support group geared toward your situation. Live a healthy lifestyle including a healthy diet and regular physical activity. Explanation: A client with a sense of accomplishment, living a healthy lifestyle including a healthy diet and regular physical activity and having a support group will improve resilience and adaptation to the stress of retirement. The client needs to be hopeful about the future and stay connected to social support such as friends and family.

A nurse is caring for a client who gave birth to a stillborn neonate at 36 weeks' gestation. Which action taken by the nurse is most helpful in helping the client cope with the loss of the baby? Let the child's father decide what information the client receives. Encourage the client to see, touch, and hold the dead neonate. Provide information about possible causes of the stillbirth only if the client requests it. Be selective in providing the information that the client seeks.

Encourage the client to see, touch, and hold the dead neonate. Explanation: When caring for a client who has suffered perinatal loss, the nurse should provide an opportunity for her to bond with the dead child and allow the child to become part of the family unit. Parents who aren't given such a chance may experience fantasies about the child, which may be worse than the reality. If the child has gross deformities, the nurse should prepare the client for these. If the client doesn't ask about her child, the nurse should encourage her to do so and provide any information she seems ready to hear. The client needs a full explanation of all factors related to the experience so she can grieve appropriately. Letting the child's father decide which information the client receives is inappropriate.

Which statement, made by a client with paranoid personality disorder, shows that education about social relationships is effective? "I'll find out what problems others have so I won't repeat them." "Sometimes I can see what causes relationship problems." "As long as I live, I won't abide by social rules." "I don't have problems in social relationships; I never really did."

Sometimes I can see what causes relationship problems." Explanation: Progress is shown when the client addresses behaviors that negatively affect relationships. Clients with paranoid personality disorder struggle to understand and express their feelings about social rules. Knowing other people's problems isn't useful; the client must focus on his own issues. Clients with paranoid personality disorder tend to have impaired social relationships and are very uncomfortable in social settings. By not recognizing the problem, the client indicates that he is in denial.

A client with borderline personality disorder dramatically expresses feelings about each nurse on the staff, stating that only one nurse is understanding and trustworthy — the nurse the client is talking to at the time. The nurse realizes this client is demonstrating which type of behavior? Empathy Splitting Gnawing Confidentiality

Splitting Explanation: In splitting, the client manipulates the staff in attempt to create conflicts between staff members. Boundaries must be set to limit the client's negative behavior. Confidentiality is the protection of client information. Empathy is the nurse's attempt to understand and respond to a client's needs and feelings. Gnawing isn't a term used in psychiatric nursing.

A licensed practical nurse is reinforcing instructions with a new group of mental health aides about setting limits for clients' inappropriate or unacceptable behavior. The nurse informs them that this action would be most important for which client? client who is suicidal client with depression client with anxiety client experiencing mania

client experiencing mania Explanation: Setting limits for unacceptable behavior is most important for a client experiencing mania. This client typically shows a lack of restraint with actions. Clients with depression or anxiety or those who are suicidal typically do not physically or mentally test the limits of the knowledgeable caregiver.

A client with dependent personality disorder is thinking about getting a part-time job. Which nursing intervention will help this client when employment is obtained? help the client decrease the use of regression as a defense mechanism help the client develop strategies to control impulses encourage the client to work to sustain healthy interpersonal relationships explain there are consequences for inappropriate behaviors

encourage the client to work to sustain healthy interpersonal relationships Explanation: Sustaining healthy relationships will help the client be comfortable with peers in the job setting. Clients with dependent personality disorder don't usually have trouble with impulse control or offensive behavior that would lead to negative consequences. They don't usually use regression as a defense mechanism. It's common to see denial and introjection used.

A client states, "I can't eat because my bowels have turned against me." The nurse determines that the client is exhibiting which behavior? hysteria illness anxiety somatic delusion depersonalization

somatic delusion Explanation: A somatic delusion, such as a client believing that his bowels have turned against him, is a fixed false belief pertaining to the body and body parts. Conversion hysteria is a somatic symmptom disorder in which there are symptoms of some physical illness without any underlying organic cause. Depersonalization is a feeling of unreality concerning self and a loss of self-identity, with things around the person seeming different, strange, or unreal. Illness anxiety disorrder is somatic overconcern with a morbid attention to details of body functioning.

"Mother verbalizing labor & delivery experience. Doesn't appear confident about holding the baby or changing diapers. Asking appropriate questions." -------------------------J.Connors, LPN. A nurse is caring for a 1-day postpartum client. The progress note above informs the nurse that the client is in which phase of the postpartum period? taking hold letting go taking in holding out

taking in Explanation: The taking-in phase is normally the first postpartum phase. During this phase, the mother feels overwhelmed by the responsibilities of newborn care and is still fatigued from delivery. Taking hold is the next phase, when the client has rested and can learn mothering skills with confidence. Letting go is the final stage, when the client adapts to parenthood, her new role as a caregiver, and her new baby as a separate entity. Holding out is not a valid phase.

When communicating with a client who has sensory (receptive) aphasia, the nurse should: give the client a writing pad. allow time for the client to respond. use short, simple sentences. speak loudly and articulate clearly.

use short, simple sentences. Explanation: Although receptive aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful, but it's less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

A nurse is preparing to reinforce education with a client who uses alcohol. What client data would be most important for the nurse to obtain? decision making sleep patterns communication skills willingness to learn

willingness to learn Explanation: It's important to know if the client's current situation helps or hinders his potential to learn. Sleep patterns, decision making, and communication skills aren't factors that must be assessed before educating clients about addiction.