NCLEX Psychosocial Integrity

turned to stone and my heart is solid!" How would the nurse identify this statement? 1. Depersonalization 2. Echopraxia 3. Neologism 4. Concrete thinking

1. Depersonalization (1. Correct: Depersonalization, which is the unstable self-identity of an individual with schizophrenia may lead to feelings of unreality (the feeling that one's parts have changed or a sense of seeing oneself from a distance). 2. Incorrect: The client who exhibits echopraxia may purposelessly imitate movements made by others. 3. Incorrect: Neologism is the invention of new words by a psychotic client. 4. Incorrect: Concrete thinking, or literal interpretations of the environment, represents a regression to an earlier level of cognitive development.)

A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. EGD, colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the symptoms. The client tells the nurse, "The doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad some times that I can't function!" What is the nurse's most appropriate response? 1. "The pain you feel is real." 2. "The primary healthcare provider is right. Your pain is not real." 3. "Let me get you an appointment with the psychiatrist." 4. "Don't worry. Everything will be ok."

1. "The pain you feel is real." (1. Correct: Pain is real even if it is psychological pain. The client is experiencing anxiety, or stress through stomach pain. The nurse should use therapeutic communication technique that is client centered and empowers the client. 2. Incorrect: This is a example of nontherapeutic communication. The response is confrontational and does not address how the client feels. 3. Incorrect: This nontherapeutic communication of changing the subject ignores the client's feelings. This action invalidates the client. 4. Incorrect: This is a nontherapeutic communication technique, because the response is trite, with false reassurance. The nurse can not know if everything will be ok for the client.)

A client diagnosed with depression asks the nurse, "What is causing me to be depressed so often?" What is the best response by the nurse? 1. "There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain. " 2. "You experience depression because of your elevated levels of thyroid hormones." 3. "The primary healthcare provider will have to explain to you what is causing your depression." 4. "Tell me what you think causes you to be depressed."

1. "There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain. " (1. Correct: Decreased levels of norepinephrine, dopamine, and serotonin are neurotransmitter implications for depression. By giving this type of information to the client, it helps with their understanding of the depression and empowers them with knowledge. 2. Incorrect: Elevated levels of thyroid hormones are thought to contribute to panic disorder or manic-type behaviors. Decreased levels of thyroid hormones are affiliated with depression, but not increased levels, so this would be wrong. 3. Incorrect: The nurse can discuss this with the client. This would be ignoring the client's desire to have information and post-pone providing much-needed help to the client. 4. Incorrect: This statement may allow for dialogue, but does not answer the client's question.)

The nurse is caring for a client on the psychiatric unit with a diagnosis of obsessive-compulsive disorder. The client has frequent hand washing rituals. Which nursing interventions would be advisable for this client? Select all that apply. 1. Allow time for ritual. 2. Provide positive reinforcement for nonritualistic behavior. 3. Provide a flexible schedule for the client. 4. Remove all soap and water sources from the client's environment. 5. Create a regular schedule for taking client to bathroom.

1. Allow time for ritual. 2. Provide positive reinforcement for nonritualistic behavior. 5. Create a regular schedule for taking client to bathroom. (1., 2. & 5. Correct: Initially meet the client's dependency needs as required to keep anxiety from escalating. Anything that increases the client's anxiety tends to increase the ritualistic behavior. Positive reinforcement for nonritualistic behavior takes the focus off of the ritual. A lack of attention to ritualistic behaviors can help to decrease the ritual. By creating a regular schedule when the client goes to the bathroom, (where the handwashing ritual occurs most frequently) allows the client a structured but limited time for the ritual. This can help give the client a sense of control of the maladaptive behavior until the client can start setting own limits on the behavior and develop more adaptive coping mechanisms. 3. Incorrect: A structured schedule is needed for this client. If the client is allowed to perform the maladaptive behavior whenever desired, the client will not begin to problem solve ways to limit the ritual nor lessen the anxiety associated with the ritualistic behavior. The set schedule helps the client to develop trust with the nurse, knowing that time will be allowed for the behavior until better coping skills are developed. 4. Incorrect: Sudden and complete elimination of all avenues for dependency would create intense anxiety in the client. This increased anxiety would only serve to increase the ritualistic behavior. When time is not allowed for the ritual, the client fears that something bad is happening and the anxiety escalates.)

A newly admitted client with schizophrenia tells the nurse, "The doctor is trying to steal my organs for science." Which response by the nurse would be most therapeutic? 1. Are you feeling afraid now? 2. I am here with you. 3. Let's discuss something else. 4. You know that is not true.

1. Are you feeling afraid now? (1. Correct: The nurse should speak to the underlying feeling of the client's statement which is fear. 2. Incorrect: The nurse is offering self. This does not respond to the underlying message in the client's statement that indicates fear and false information. 3. Incorrect: The nurse is changing the subject. This is a non-therapeutic response by the nurse that will decrease communication between the nurse and the client. 4. Incorrect: The nurse is arguing with the client. This is a non-therapeutic response by the nurse that will decrease communication between the nurse and the client.)

A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual? Select all that apply. 1. Attend an activity with the client who is reluctant to go alone. 2. Allow the client to break an insignificant rule. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when the client is hungry.

1. Attend an activity with the client who is reluctant to go alone. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when the client is hungry. (1., 3., 4. & 5. Correct: Trust is demonstrated through nursing interventions that convey a sense of warmth and care to the client. These interventions are initiated simply, concretely, and directed toward activities that address the client's basic needs for physiological and psychological safety and security. Concrete thinking focuses thought processes on specifics, rather than generalities, and immediate issues, rather than eventual outcomes. Examples of nursing interventions that would promote trust in an individual who is thinking concretely include such things as: providing a blanket when the client is cold, providing food when the client is hungry, keeping promises, being honest, providing a written, structured schedule of activities, attending activities with the client if he is reluctant to go alone, being consistent in adhering to unit guidelines, and taking the client's preferences, requests, and opinions into consideration when possible in decisions concerning care. 2. Incorrect: The client should be informed of all rules, simply and clearly, with reasons for certain policies and rules. Be consistent and provide written, structured, scheduled activities. Allowing a client to break a rule would not encourage them to think about the outcomes of their actions.)

Which interventions should the nurse include when planning care for a client diagnosed with paranoid personality? Select all that apply. 1. Develop a trusting relationship. 2. Be honest when communicating with the client. 3. Encourage the client to participate in group therapy. 4. Encourage the client to clean the day room daily. 5. Give clear explanations of procedures before hand.

1. Develop a trusting relationship. 2. Be honest when communicating with the client. 5. Give clear explanations of procedures before hand. (1., 2. & 5. Correct: This disorder is characterized by distrust and suspicion towards others. The nurse should use open communication techniques to increase the client's trust in the nurse. Clear explanations of procedures will decrease the anxiety of the client. 3. Incorrect: The client with paranoid personality is reluctant to share personal information with other people. They suspect everyone of causing problems for them. Group therapy would not be appropriate for this client. 4. Incorrect: The client with paranoid personality feels that others are using or exploiting them. The client may perceive that they are being exploited if they clean the dayroom.)

A nurse is planning to provide information regarding suicide to a high school assembly. What information should the nurse include? Select all that apply. 1. Do not keep secrets for the suicidal person. 2. Express concern for a person expressing thoughts of suicide. 3. Teens often don't mean what they say, so only take suicide seriously if grades are dropping as well. 4. Inform group of suicide intervention sources. 5. Do not leave a suicidal person alone.

1. Do not keep secrets for the suicidal person. 2. Express concern for a person expressing thoughts of suicide. 4. Inform group of suicide intervention sources. 5. Do not leave a suicidal person alone. (1., 2., 4. & 5. Correct: If a person reveals that suicide is being considered, this should never be kept secret. Help should be sought for the person immediately. It is also important to be direct and non-secretive with suicidal clients. It is appropriate to express concern for their thoughts. The use of empathy, warmth and concern indicates to the client that their feelings are being understood and viewed as real, which helps to build trust with the client. Resources for assistance are important to include in all health teaching programs. The teens need to know what resources are readily available if someone is considering suicide. The client contemplating suicide should not be left alone. This is for the client's safety until further assistance can be obtained 3. Incorrect: Most clients who commit suicide have told at least one person that they were contemplating suicide before thy actually committed the act. Therefore, suicidal comments should be considered important risk factors that require evaluation, and all comments should be taken seriously. Anyone expressing suicidal feelings needs immediate attention.)

The nurse is caring for a client suffering from major depression. The client spends all day in bed. Which nursing action is appropriate? 1. Frequently initiate contact with client. 2. Frequently round at regular intervals. 3. Patiently wait for the client to come out of the room. 4. Question the client about reason for not getting out of the bed.

1. Frequently initiate contact with client. (1. Correct: Be accepting of, and spend time with the client. The client may exhibit pessimism and negativism. The nurse should focus on strengths and accomplishments, and minimize failures. 2. Incorrect: During depressive episodes the client's judgment and problem solving skills are decreased. The nurse should round at frequent, irregular intervals so that the client does not know when to expect the nurse and then can attempt suicide. 3. Incorrect: The nurse should seek out the client. The client may exhibit psycho motor retardation such as lethargy and fatigue. The depressed client is not likely to come looking for someone. 4. Incorrect: Do not confront the client about lack of activity. This will not promote trust. The client may not know why. The client may also have decreased ability to comprehend the question and formulate an answer.)

A nurse is preparing to conduct a presentation on barriers to therapeutic communication with clients from a culture other than the nurse's culture. Which points should the nurse include in the presentation? Select all that apply. 1. Lack of knowledge about a client's culture is a major barrier to therapeutic communication. 2. Follow cultural beliefs when caring for all clients of that particular culture. 3. Ethnocentrism facilitates therapeutic communication. 4. Do not touch the client until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and preferences.

1. Lack of knowledge about a client's culture is a major barrier to therapeutic communication. 4. Do not touch the client until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and preferences. (1., 4. & 5. Correct: Nurses must understand and take into consideration the cultural differences of their clients. Some cultures do not approve of touching or shaking hands. By assessing the client's culture preference, the nurse is able to provide individualized care. 2. Incorrect: Do not stereotype all clients of a certain culture. Ask questions. Allow for individuality. To provide culturally competent care, the nurse must recognize individual preferences within the client's culture. 3. Incorrect: Ethnocentrism is the belief that one's own culture and traditions are better than those of another. It blocks therapeutic communication by allowing the nurse's biases and prejudices to negatively influence the nursing care of the client.)

A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. How should the nurse communicate with this client? 1. Use simple words. 2. Speak loudly to the client. 3. Do not speak to the client at this time. 4. Use open-ended questions to ask what is wrong.

1. Use simple words. (1. Correct: Use simple words, because the client cannot comprehend anything but the most elemental communications during a panic attack. 2. Incorrect: A calm, low level of intensity to reduce anxiety is needed. Speaking loudly will increase the client's anxiety. 3. Incorrect: Calm, simple words are needed instead of silence which could be interpreted as ignoring the client. 4. Incorrect: Simple communication of reassurance needed. This is not the time for open ended questions and would increase the client's anxiety.)

The nurse is caring for a client admitted to the psychiatric unit with a diagnosis of major depression. What behaviors could the nurse expect upon Select all that apply. 1. Withdrawn behavior 2. Sitting in room, lights out, drapes closed 3. Unkempt appearance 4. Overeating 5. Severe insomnia

1. Withdrawn behavior 2. Sitting in room, lights out, drapes closed 3. Unkempt appearance 5. Severe insomnia (1., 2., 3., & 5. Correct: The client with severe depression has extremely low self-esteem and low energy levels and may just sit for hours. Depressed clients prefer to be alone and avoid social interactions. The room environment mimics the mood of the client (dark and gloomy). The client may not have the energy to bathe, change clothes, or even comb hair. The severely depressed person may have severe insomnia. However, sleeping too much is also a symptom of mild depression. 4. Incorrect: The client who is severely depressed, as in the depressive disorder, usually has no appetite and loses weight. A mildly depressed client is more likely to overeat as a coping mechanism.)

The nurse is giving discharge instructions to an Asian client following a colonoscopy. During the instructions, the client stares directly at the floor, despite being able to speak English. Based on the client's body language, how would the nurse classify this behavior? 1. Embarrassment. 2. Attentiveness. 3. Disinterest. 4. Confusion.

2. Attentiveness. (2. Correct: Nurses must be aware of clients' specific cultural or religious beliefs in order to provide appropriate care and discharge planning. Asian societies have a deep respect for others and making eye contact with the nurse would be considered rude and offensive. The nurse is considered superior to the client, so direct eye contact with a superior shows a lack of respect. This client is displaying attentiveness while also showing respect for the nurse. 1. Incorrect: There is nothing in the question to suggest the client is embarrassed. In Asian cultures, making eye contact is considered disrespectful to the superior; therefore, this client's demeanor is a respectful display of cultural influences. 3. Incorrect: The client's body language does not suggest disinterest. Although staring downward, this client does not display other signs of disinterest. A culturally aware nurse understands that the client's Asian background impacts this behavior and conveys the meaning of respect for the nurses' position. 4. Incorrect: The question indicates that the client does speak English. There is no indication that the client is confused or does not comprehend the discharge instructions. There is a more specific cultural basis for the client's behavior.)

The occupational health nurse is leading a group discussion about addiction. What should the nurse include as the primary barrier to the client with alcohol addiction seeking treatment? 1. Co-dependency 2. Denial 3. Depression 4. Stigma

2. Denial (2. Correct: They reject that they have a drinking problem and will argue with you if you suggest it. The client with an addiction may also use denial to lessen the impact of their addiction. 1. Incorrect: Co-dependency makes alcohol abuse last longer, but this is not the reason they do not seek treatment. Persons with co-dependency have difficulty establishing healthy relationships. 3. Incorrect: No depression associated with substance abuse. The primary reason a person does not seek treatment is denial of their addiction. 4. Incorrect: Yes, clients may be afraid of the stigma associated with addiction recovery. The person must first address their denial of addiction issues.)

A client diagnosed with major depression is admitted to the psychiatric unit for electroconvulsive therapy (ECT). The client asks the nurse, "How many of these treatments do you think I will need?" What is the nurse's best response? 1. That is a question you need to discuss with your primary healthcare provider. 2. Everyone responds differently, but on average clients need 6-12 treatments. 3. You will need to take a treatment every month for at least a year. 4. Let's just take one treatment at a time, shall we?

2. Everyone responds differently, but on average clients need 6-12 treatments. (2. Correct: Most clients require an average of 6 to 12 treatments, but some may require up to 20 treatments. These treatments are generally given two to three times per week for three to four weeks. The number of treatments required depends on the severity of the symptoms and how quickly the client improves. 1. Incorrect: The nurse should be able to answer this question based upon the generally accepted regimen for electroconvulsive therapy (ECT). 3. Incorrect: Treatments are usually administered every other day (three times per week). Since the average number of treatments is 6-12, it only takes a couple of weeks to a month, on average for the regimen. Treatments are performed on an inpatient basis for those who require close observation and care, but can be done on an outpatient basis for some clients. 4. Incorrect: This is poor therapeutic communication. The nurse did not answer the question and is belittling. The client has a right to be able to make informed decisions regarding care being provided.)

What symptoms does the nurse expect to see in a client with bulimia nervosa? Select all that apply. 1. Amenorrhea 2. Feelings of self-worth unduly influenced by weight 3. Recurrent episodes of binge eating 4. Recurrent inappropriate compensatory behavior to prevent weight gain 5. Lack of exercise

2. Feelings of self-worth unduly influenced by weight 3. Recurrent episodes of binge eating 4. Recurrent inappropriate compensatory behavior to prevent weight gain (2., 3. & 4. Correct: Diagnostic criteria for bulimia nervosa are recurrent episodes of binge eating: recurrent inappropriate compensatory behavior to prevent weight gain such as laxative, diuretic, or enema use, induced vomiting, fasting, and excessive exercise; and feeling of self-worth unduly influenced by weight. Amenorrhea is found in anorexia nervosa. 1. Incorrect: Amenorrhea is found in anorexia nervosa. 5. Incorrect: Excessive exercise is found in bulimia nervosa as a means to compensate for the binge eating.)

A newly admitted client with schizophrenia has an unkempt appearance and needs to attend to personal hygiene. Which statement by the nurse is most therapeutic? 1. A shower will make you feel better. 2. It is time to take a shower. 3. Have you thought about taking a shower? 4. I need you to take a shower.

2. It is time to take a shower. (2. Correct: Schizophrenia is a thought disorder. Many clients with schizophrenia are concrete thinkers and have difficulty making decisions. The nurse needs to be direct, clear and concise in communicating with the client. This is a direct, clear and concise statement that guides the client to perform the needed activity. 1. Incorrect: Many clients with schizophrenia are concrete thinkers. The nurse needs to be direct, clear and concise in communicating with the client. The client may not comprehend how the shower improves the overall sense of well-being and would remain reluctant to take the shower. 3. Incorrect: Clients diagnosed with schizophrenia often have trouble making decisions. The client needs to be guided with simple, direct instructions. 4. Incorrect: This focuses on the nurse's need, not the client's need. Do not select answers that focus on the nurse. This does not improve the client's decision making ability nor does it provide guidance to the client for meeting the hygiene needs.)

A soldier who returned from combat 2 months ago was admitted to a psychiatric unit with a diagnosis of Dissociative Fugue. The police found the client wandering down the street in a daze after fighting with a stranger. Which nursing interventions should the nurse implement? Select all that apply. 1. Directly observe the client at least every 4 hours. 2. Maintain a low level of stimuli. 3. Remove all dangerous objects from environment. 4. Convey a calm attitude toward the client. 5. Discourage client's expression of negative feelings.

2. Maintain a low level of stimuli. 3. Remove all dangerous objects from environment. 4. Convey a calm attitude toward the client. (2., 3. & 4. Correct: Anxiety rises in stimulating environments. Individuals may be perceived as threatened by a fearful and agitated client. Removing dangerous objects will prevent the confused and agitated client from using them to harm self or others. Anxiety is contagious and can be transmitted from staff to client. 1. Incorrect: The client should be observed closely and frequently to ensure safety for self and others. Every 4 hours is not frequent enough and doesn't ensure the client's safety. 5. Incorrect: Accepting expression of negative feelings is therapeutic and helps the client learn more effective ways of dealing with anger, anxiety or aggression.)

A client diagnosed with schizophrenia tells the nurse, "God is going to heal me. I do not need medication." Which response by the nurse would best promote compliance with the prescribed medication regimen? 1. Yes, I believe that God will heal you. 2. Many people of faith believe that one way God works to heal is through medication. 3. We are talking about taking your medications right now. 4. What if God does not heal you and you should have taken the medication?

2. Many people of faith believe that one way God works to heal is through medication. (2. Correct: This allows the client to keep the belief that God will heal but will do it through the medication. This promotes compliance with the prescribed medication regimen. 1. Incorrect: The nurse does not know if God will heal the client and does not promote compliance with the prescribed medication regimen. 3. Incorrect: This approach may make the client angry, which will close the communication between the client and the nurse. It also does not promote compliance with the prescribed medication regimen. 4. Incorrect: This approach is argumentative and puts the client on the defense, which will close the communication between the client and the nurse.)

A home care nurse is preparing to perform venipuncture to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What should be the nurse's first action? 1. Hug the client to provide support. 2. Take the client to the emergency department for sedation. 3. Decrease stimuli in the room. 4. Teach the client deep breathing exercises.

3. Decrease stimuli in the room. (3. Correct: The nurse should remain calm and quiet by the client. A stimulating environment may increase the client's level of anxiety. 1. Incorrect: Hugging a client is moving into the client;s personal space. Hugging may confine the person and intensify feelings. The nurse should use touch cautiously. 2. Incorrect: Panic attacks usually last minutes, rarely longer. The client is not exhibiting symptoms at this time that would warrant administration of a sedative. 4. Incorrect: This is good; however, you need to wait until the panic attack is over. The client must be ready to learn prior to initiating teaching. The nurse should wait until the symptoms resolve for learning to occur.)

The client has suicidal ideations with a vague plan for suicide. The nurse who is teaching the family to care for the client at home should emphasize which points? Select all that apply. 1. Family members are responsible for preventing future suicidal attempts. 2. When the client stops talking about suicide, the risk has increased. 3. Warning signs, even if indirect, are generally present prior to a suicide attempt. 4. One suicide attempt increases the chance of future suicide attempts. 5. Report sudden behavioral changes.

2. When the client stops talking about suicide, the risk has increased. 3. Warning signs, even if indirect, are generally present prior to a suicide attempt. 4. One suicide attempt increases the chance of future suicide attempts. 5. Report sudden behavioral changes. (2., 3., 4. & 5. Correct: A common myth is that the person who doesn't talk about suicide will not attempt it, but this may be a warning sign that the person has a well thought out plan. Warning signs generally exist but may not be recognized by others until after the suicide or attempted suicide. Once a person has made a suicidal attempt, the chances increase that they will attempt it again at a later time. Sudden behavioral changes can signal suicidal intentions, especially if that is the primary focus of their thoughts and feelings. 1. Incorrect: Families should be encouraged to create a safe environment and recognize warning signs, but they may not be able to stop a suicide. Families, in spite of their best efforts, should not be put into a position of guilt if the client is successful with suicide.)

The nurse is caring for a client in the emergency department after a violent altercation with her husband. She describes increasingly violent episodes over the past 10 years. She says, "This is the last time he will hit me." Which response by the nurse demonstrates understanding of the violence cycle? 1. When you leave, you don't have to worry anymore. 2. You are at greatest risk when you leave. 3. That is the best decision you can make. 4. I am glad that you won't be hurt ever again.

2. You are at greatest risk when you leave. (2. Correct: Violence is likely to escalate and may become lethal when the spouse leaves the abusive partner. The risk of death or injury is highest at the time the abused person decides to leave the abusive relationship or shortly after leaving. 1. Incorrect: Just because the victim leaves does not guarantee that the abuser will not follow or find her. The threat of injury or death increases at the time the abused person leaves. This response is giving false reassurance to the abused person. 3. Incorrect: The client should be praised; however, there are risks with both leaving and staying. The client should be informed. The nurse should acknowledge the fear of staying in the relationship and guide the client to resources that can be used to help make informed decisions. 4. Incorrect: Leaving the home and the perpetrator do not guarantee cessation of violence. Again, this only provides false reassurance that the abuser will not find the client and inflict harm.)

A client who has been on a psychiatric unit because of several attempted suicides states, "I am happy to be going home today." What is the nurse's best analysis of this statement? 1. No longer has depression. 2. Has developed appropriate coping mechanisms. 3. May have decided on another suicide plan. 4. Is happy to go home and see family.

3. May have decided on another suicide plan. (3. Correct: Clients who have attempted suicide may come up with another plan. Once they do, they are generally happy, satisfied, and begin giving away personal belongings. Clients usually exhibit some trepidation about leaving the hospital. 1. Incorrect: This cannot be determined by the client's statement. Suicidal depression is not a short term problem, but requires intense therapy. 2. Incorrect: Always assume the worse until proven otherwise. The client's statement does not reflect an increase in their coping mechanism. The suicide client may have planned another suicide attempt. 4. Incorrect: This cannot be determined by the client's statement. The client said nothing about family. There is no data to identify the client's family relationships.)

A teenage client is placed on life-support as a result of a motor vehicle accident (MVA). Following an electroencephalogram (EEG), the client has been declared brain dead. Which action by the nurse would take priority? 1. Call the respiratory department to have the ventilator removed. 2. Notify the facility's pastoral personnel. 3. Contact the regional organ procurement team. 4. Ask the family to select a funeral home.

3. Contact the regional organ procurement team. (3. Correct: The first priority is to notify the designated organ procurement team. These personnel are trained to determine if the client would be an appropriate donor, how to approach the grieving family and discuss options, and to make any necessary arrangements in such a situation. Time is of the essence in the case of organ donation. Even if the family refuses to donate organs, it is the Procurement Team that will deal with the situation. 1. Incorrect: Although the Respiratory department may be present at the time of extubation, removing the ventilator from the room is not a priority at this time. The client will most likely remain on the ventilator until the Procurement Team has talked with the family. 2. Incorrect: The facility pastoral staff may already be aware of the critical nature of this situation, and the family may have also gathered their own support group at this time. Though the nurse may notify hospital's support personnel, this would not be the first priority action. 4. Incorrect: While the family will have to make many difficult decisions in this situation, the nurse must focus on the client first. Time is crucial for organ viability, and the Organ Procurement Team needs to mobilize appropriate personnel to deal with all issues.)

An elderly male, diagnosed with chronic renal failure and depression, lives alone. Which question should the home health nurse ask first when assessing this client? 1. Have you had suicidal thoughts in the past? 2. How are you feeling today? 3. Have you had thoughts of harming yourself? 4. Do you have guns in your home?

3. Have you had thoughts of harming yourself? (3. Correct: Suicide assessment should begin with direct questions about the presence of suicidal thinking. The nurse should recognize that elderly men are at higher risk for committing suicide, especially those with a history of depression, chronic illness and isolation. 1. Incorrect: This question should be asked, but only after determining if suicidal thinking is present. 2. Incorrect: This question could be an introductory question to establish rapport, but it is not direct enough to use in suicide assessment. 4. Incorrect: This question should be asked if the client is considering using gun as a method of suicide or if he has a history of suicide attempts with a gun.)

A client was admitted to the psychiatric unit with delusions and a history of auditory hallucinations. The client reports, "The FBI has been watching my house and are going to raid it and arrest me." What is the nurse's best response? 1. The FBI would not be watching you unless there was a good reason. 2. I don't think that the FBI is watching your house. 3. I believe that your thoughts are very disturbing to you. 4. Tell me more about your thoughts.

3. I believe that your thoughts are very disturbing to you. (3. Correct: The client's delusions can be very distressing. The nurse should empathize with the feelings of the client, but should not validate the belief itself. Empathy displays that the nurse is concerned, interested, and accepts the client but does not support the delusion. 1. Incorrect: Arguing with the client who has delusions only upsets the client and may provoke violence. The client can not understand the logical argument, so the delusional ideas are not dispelled. Also, the argument can interfere with the development of trust. 2. Incorrect: Disagreement may anger the client. The client needs empathy and understanding from the nurse. This is dismissing the client's feelings. The focus should not be on what the nurse thinks. The focus should always be on the client's feelings. 4. Incorrect: In-depth detail of delusions only reinforces the delusion. The nurse should encourage reality based conversation. Interacting about reality is beneficial for the client to move them away from delusional thoughts.)

During evening rounds, the nurse discovers that a violent client with a history of threats against a former girlfriend cannot be located. The client's window is open and personal belongings missing. Based on recent threats of violence against the girlfriend, what is the nurse's initial action? 1. Look for the client quietly to maintain confidentiality. 2. Notify the local police to organize a search party. 3. Initiate the missing client protocol. 4. Complete an "Against Medical Advice" (AMA) form on the client's elopement.

3. Initiate the missing client protocol. (3. Correct. Since the client is missing and is considered to be a risk to himself or others, the missing client protocol is immediately implemented. A organized and escalating search for the client will occur. 1. Incorrect. Although HIPAA is very precise on the issue of confidentiality, privacy is waived in specific, extreme situations that involve the life of a client, staff, or family. While the nurse may alert staff members to help search the building or facility grounds, this is not the initial action of the nurse. 2. Incorrect. Although local police may eventually be asked to assist in locating the client, this decision will be made by the facility's administrative personnel. However, this is not the initial action under the stated circumstances. 4. Incorrect. An Against Medical Advice (AMA) form is signed by a client who decides to leave a facility without treatment, against the advice of the primary healthcare provider. That form does not apply in this situation since the client has already left. This event falls under the category of elopement.)

A confused elderly client is brought to the emergency department by a family member who states the client fell down a flight of stairs. In addition to multiple facial contusions, x-rays reveal a spiral fracture of the left forearm. After assisting the primary healthcare provider in applying a short arm cast, the nurse identifies which action as a priority in discharge planning? 1. Ask the family to restrict the client to the first floor. 2. Instruct the client on home safety issues. 3. Notify social services to arrange a home visit. 4. Discuss cast care with client and family.

3. Notify social services to arrange a home visit. (3. Correct: The nurse is aware that a spiral fracture is caused by a twisting or jerking motion, in this case, of the forearm. While a fall could cause many injuries, contusions of the face combined with a spiral forearm, are indicative of abuse. The priority is to alert social services to follow-up with this client and family in the home setting, to determine the severity of the situation and possible interventions for the client's well-being. 1. Incorrect: The family reported that the client fell down the steps; however, the nurse notes evidence to the contrary. Confining the client to one floor of the residence does not guarantee that the client will remain safe or uninjured in the future. 2. Incorrect: The information indicates that the client is confused, so teaching presented to the client would not be as appropriate as discussing safety issues with the family. However, in this case, home safety is not the issue that needs addressed by the nurse. 4. Incorrect: Although the family will need to know how to care for the client's cast at home, this is not the priority issue in this situation.)

The nurse is planning daily activities for a client who has a diagnosis of schizophrenia. The client tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for this client? 1. Watching TV with two other clients in the day room. 2. Watching TV alone in a conference room. 3. Spending time in brief one on one interactions with the nurse. 4. Sitting in the day-room away from other clients.

3. Spending time in brief one on one interactions with the nurse. (3. Correct: The interaction with the nurse can keep the conversation reality based and provide interaction with someone. Clients with schizophrenia may be very withdrawn and need the presence of the nurse. 1. Incorrect: The client is very uncomfortable around the other clients. This action could be appropriate as the client's condition begins to stabilize. 2. Incorrect: The client needs interaction with others. Time with others allows the client to stay reality based. When alone, there may be more time for delusional thought or auditory hallucinations. 4. Incorrect: The nurse can assess the thought processes of the client and offer acceptance of the client. Sitting away from other clients is not recommended therapeutic intervention for this client.)

A newly admitted client tells the nurse, "I am hearing voices." Which response by the nurse is most appropriate? 1. Your head is turned to the side as if you are listening to voices. 2. I don't hear anyone but you speaking. 3. Tell me what the voices are saying to you. 4. Let's talk about your anxiety right now.

3. Tell me what the voices are saying to you. (3. Correct: The nurse needs to know what the voices are saying to the client. This is the first thing the nurse would ask if the newly admitted client tells the nurse about hearing voices. The nurse does not know the client or the diagnosis that might be affiliated with this statement. 1. Incorrect: The client has already told the nurse about hearing voices. This also is non-therapeutic and negates the value of what the client is saying. 2. Incorrect: Upon admission, the nurse would not start out with this comment. This would come later. First the nurse needs to know what the voices are telling the client. 4. Incorrect: Again, this would come later after the nurse finds out what the voices are telling the client.)

A client was admitted to the medical unit with pneumonia 2 days ago. There is a history of drinking 5-6 martinis every night for the past 2 years. Today, the nurse notes that the client is disoriented to time and place and is seeing imaginary spiders on the ceiling. The nurse cannot understand what the client is saying. What is this client most likely experiencing? 1. Wernicke's Encephalopathy 2. Korsakoff's Psychosis 3. Alcohol Withdrawal 4. Alcohol Withdrawal Delirium

4. Alcohol Withdrawal Delirium (4. Correct: Alcohol Withdrawal Delirium usually occurs on the second or third day following cessation of or reduction in prolonged, heavy alcohol use. Symptoms are the same as for delirium: Difficulty sustaining and shifting attention. Extremely distractible; disorganized thinking; rambling, irrelevant, pressured, and incoherent speech; impaired reasoning ability; disoriented to time and place; impairment of recent memory; delusions and hallucinations. 1. Incorrect: Wernicke's Encephalopathy represents the most severe form of thiamine deficiency in alcoholics. Symptoms include paralysis of the ocular muscles, diplopia, ataxia, confusion, somnolence, and stupor. If thiamine replacement therapy is not given, death will ensue. 2. Incorrect: Korsakoff's Psychosis is identified by a syndrome of confusion, personality changes, loss of recent memory, and confabulation (filling in some memory gaps with different life events or created thoughts). It is frequently encountered in clients recovering from Wernicke's encephalopathy. Coordination may be affected, so the client may have difficulty maintaining balance. Treatment is parenteral or oral thiamine replacement. 3. Incorrect: Alcohol withdrawal typically begins 4-12 hours after cessation of or reduction in heavy and prolonged alcohol use. Symptoms include: coarse tremor of hands, tongue, or eyelids; nausea and vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood or irritability; transient hallucinations or delusions; headache; and insomnia.)

The nurse is planning care for a newly admitted client who has an Arabic surname and whose spouse is wearing a traditional head covering. After verifying that the client prescriptions include a regular diet as tolerated, how would the nurse best meet the religious dietary needs for this client? 1. Allow the client to select whatever is acceptable from a regular meal tray. 2. Review the client's admission data to determine any dietary restrictions. 3. Call the dietician to discuss special dietary needs with the client's spouse. 4. Ask the client about dietary preferences needed to meet religious guidelines.

4. Ask the client about dietary preferences needed to meet religious guidelines. (4. Correct. Nurses must be aware of cultural, religious and spiritual beliefs as an important aspect in clients' health and recovery. This nurse suspects possible cultural or religious implications that may require special dietary alterations for the client, even though the primary health care provider prescribed a regular diet. Asking the client directly about dietary preferences or restrictions is the best approach, since individuals vary when adhering to religious practices. 1. Incorrect. When assessing a newly admitted client, the nurse's responsibility is to determine any special cultural or religious restrictions, which might affect care and recovery. Although the nurse correctly believes certain dietary modifications may be needed for this client, asking the client to select only acceptable items from a regular tray would not meet basic nutritional requirements or cultural expectations. 2. Incorrect. Although there may be some diet information in the hospital admission forms, the nurse must do a thorough assessment when a client arrives on the floor, including determining any special spiritual or cultural needs. Obtaining information from the hospital chart does not ensure accurate or detailed information, and may have errors that would cause the client stress or even offend the client. 3. Incorrect. Unless the client was unconscious, there is no need for the dietician to speak to the spouse, except under certain strict cultural situations in which the spouse is expected to speak for the client. This question does not indicate either of these situations. If the nurse feels the assistance of the dietician is needed to discuss specific foods or food preparation criteria, the dietician should speak directly to the client.)

A client in a psychiatric unit sings over and over, "It is hot, I am a hot tot in a lot, I sit all day on a cot drinking a pop." How should the nurse document this form of thought? 1. Neologisms 2. Dissociation 3. Fugue 4. Clang Association

4. Clang Association (4. Correct: Clang association involves the choice of words governed by sounds, often taking the form of rhyming even though the words themselves don't have any logical reason to be grouped together. 1. Incorrect: The psychotic person invents new words, or neologisms, that are meaningless to others but have symbolic meaning to the psychotic person. 2. Incorrect: Dissociation is the splitting off of clusters of mental contents from conscious awareness. It is a mental process that leads to a lack of connection in the client's thoughts, memory and sense of identity. In its mild form, it is similar to day dreaming. In a more severe form, it can be manifested as multiple personalities. 3. Incorrect: Fugue is sudden, unexpected travel away from home or customary place of daily activities, with inability to recall some or all of one's past. The person is unaware that anything has been forgotten. Following recovery, there is no memory of the time during the fugue.)

The unlicensed assistive personnel (UAP) reports to the nurse that a client with Alzheimer's has been walking into rooms on the unit and stating, "This is my room, so get out!" What is the best instruction the nurse can give to the UAP? 1. Calmly sit with the client and have the client repeat the room number at frequent intervals. 2. Have the client remain in the room so the client can become familiar with it. 3. Place a sign on the client's door that clearly has the client's name so the client can identify it. 4. Hang a familiar object on the door to enhance room recognition.

4. Hang a familiar object on the door to enhance room recognition. (4. Correct: A client with Alzheimer's is likely to recognize a familiar object before reading the name on the door. 1. Incorrect: You can make the client repeat the room number over and over, but he or she will not remember it particularly since it is short-term current memory. This is the part of memory that goes first with the Alzheimer's client. 2. Incorrect: Stay in your room until you get used to it? No, this is non-therapeutic for a client with Alzheimer's and could increase their confusion and moody behavior. 3. Incorrect: This seems like an appropriate answer, but clients with Alzheimer's may not recognize their own name or take the time to read.)

During a conversation with a client on a psychiatric unit the client tells the nurse, "Everyone here hates me." Which response by the nurse is best? 1. No, they do not hate you. 2. What did you do to make others not like you? 3. Just don't pay attention to what others think of you. 4. I can't speak for the other people, but I don't hate you.

4. I can't speak for the other people, but I don't hate you. (4. Correct: Here the nurse is speaking only for the nurse. The nurse cannot legitimately speak for anyone else. The nurse must model the process of not speaking for anyone else. The response also lets the client know that the nurse cares about the way the client feels. 1. Incorrect: This is arguing and defending which are non-therapeutic communication techniques. The nurse does not know how the others on the unit feel about the client, so this may not be a true statement. Arguing with a client's belief can further upset or anger the client and leads to mistrust of the nurse. 2. Incorrect: This is agreeing with the client that everyone hates the client. It also puts the client on the defense by implying that the client is at fault for doing something that made everyone hate the client. This response reinforces the client's false belief. 3. Incorrect: This is using denial. This is where the nurse denies that a problem exists and blocks the discussion with the client. This avoids helping the client identify and explore the problem. This also dismisses the client's feelings.)

A parent tells the clinic nurse, "My child has just been diagnosed with attention-deficit/hyperactivity disorder (ADHD). What will be done to help my child?" How should the nurse best respond to the parent? 1. The primary healthcare provider will want to start your child on a central nervous system (CNS) depressant in order to decrease hyperactivity and improve attention. 2. You will need to admit your child to the psychiatric behavioral unit so that group therapy can be initiated. 3. Children are often placed on central nervous system stimulants that improve behavior associated with ADHD. 4. The standard of care for children with ADHD includes central nervous system stimulants along with behavior and family therapy.

4. The standard of care for children with ADHD includes central nervous system stimulants along with behavior and family therapy. (4. Correct: Multimodal treatment of ADHD is the standard of care for children. There is a lot to be gained by supporting medication treatment with appropriate educational, psychosocial, and family interventions. 1. Incorrect: Central nervous system (CNS) depressants are not appropriate therapy for ADHD. Central nervous stimulants are recommended to manage ADHD symptoms. 2. Incorrect: Children with ADHD are not generally hospitalized. Outpatient behavior therapy is recommended to assist the client to substitute positive behaviors with nonproductive behaviors. 3. Incorrect: Central nervous system stimulants are given to children with ADHD. This is a true statement, but the standard of care also includes behavior and family therapy.)