Psychiatric-Mental Health Practice Exam HESI###

A nurse notes that haloperidol (Haldol) is most effective for clients who exhibit behavior that is: 1 Depressed 2 Withdrawn 3 Manipulative 4 Overactive

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A nurse, planning care for a client who is an alcoholic, knows that the most serious life-threatening effects of alcohol withdrawal usually begin after a specific time interval. How many hours after the last drink do they occur? 1 8 to 12 2 12 to 24 3 72 to 96 4 24 to 72

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A client who is taking lithium arrives at the mental health center for a routine visit. The client has slurred speech, has an ataxic gait, and complains of nausea. The nurse knows that these signs and symptoms are: 1 Related to a low lithium level 2 Associated with cyclic mood disorders 3 Often related to a therapeutic lithium level 4 Probably associated with a toxic level of lithium

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A nurse is working with clients with a variety of eating disorders. Which characteristic unique to bulimia nervosa differentiates this disorder from anorexia nervosa? 1 The client has a distorted body image and sees the body as fat. 2 The client behaves appropriately and looks normal. 3 The client is obese and attempting to lose weight. 4 The client is struggling with a conflict of dependence versus independence.

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At what age is a client in Freud's phallic stage of psychosexual development and Erikson's psychosocial phase of initiative versus guilt? 1 3 to 5 years 2 Adolescence 3 6 to 12 years 4 Birth to 1 year

1Three to 5 years is Freud's phallic stage and Erikson's stage of initiative versus guilt. Adolescence is Freud's genital stage and Erikson's stage of identity versus role confusion. Six to 12 years is Freud's latency stage and Erikson's stage of industry versus inferiority. Birth to 1 year is Freud's oral stage and Erikson's stage of trust versus mistrust.

A client is admitted to a mental health facility because of maladaptive coping behavior. How can the nurse best help the client develop healthier coping mechanisms? 1 By providing a stress-free environment 2 By promoting interpersonal relationships with peers 3 By allowing the client to assume responsibility for decisions 4 By setting realistic limits on the client's maladaptive behavior

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A 17-year-old client is found to have anorexia nervosa. The psychiatrist, in conjunction with the client and the parents, decides to institute a behavior modification program. The nurse recalls that a major component of behavior modification is: 1 Reducing necessary restrictions 2 Deconditioning fear of weight gain 3 Reducing anxiety-producing situations 4 Rewarding positive behavior

4In behavior modification, positive behavior is reinforced and negative behavior is not reinforced or punished. Reducing the number or complexity of necessary restrictions, deconditioning the fear of weight gain, and reducing the number of anxiety-producing situations may all be part of the program, but none is a major component.

A client arrives at the mental health clinic disheveled, agitated, and demanding that the nurse "do something to make these feelings stop." What clinical manifestation is evident? 1 Suicidal tendencies 2 Narcissistic ideation 3 Demanding personality 4 Feelings of panic

4The client can no longer control or tolerate these overwhelming feelings and is seeking help. The client has not indicated plans for self-harm. Narcissistic ideation is not typical of a narcissistic personality. The client's behavior does not indicate a demanding personality.

39. A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? A) No one is after you, you're safe here. B) You'll feel better after you have rested. C) I know you must feel lonely and frightened. D) Come with me to your room and I will sit with you.

(D) is the best response because it offers support without judgment or demands. (A) is arguing with the client's delusion. (B) is offering false reassurance. (C) is a violation of therapeutic communication in that the nurse is telling the client how she feels (frightened and lonely), rather than allowing the client to describe her own feelings. Hallucinating and/or delusional clients are not capable of discussing their feelings, particularly when they perceive a crisis. Correct Answer(s): D

32. The nurse is leading a "current events group" with chronic psychiatric clients. One group member states, "Saddam Hussein was my nurse during my last hospitalization. He was a very mean nurse and wasn't nice to me." Which response is best for the nurse to make? A) Saddam Hussein was not your nurse. B) What did he do to you that was so mean? C) I didn't know that Saddam Hussein was a nurse. D) I agree that Saddam Hussein is not a very nice man.

(D) presents the reality of the situation (the individual is not nice) in relation to American culture. The fact that Saddam Hussein is not a nurse should be addressed on an individual basis. Since this is group therapy, the nurse would be illustrating the concept of universality. (A) is likely to promote defensiveness. (B and C) would support the delusion. Correct Answer(s): D

4. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is most appropriate for the nurse to make? A) I'll leave your tray here. I am available if you need anything else. B) You're not being poisoned. Why do you think someone is trying to poison you? C) No one on this unit has ever died from poisoning. You're safe here. D) I will talk to your healthcare provider about the possibility of changing your diet.

(A) is the best choice cited. The nurse does not argue with the client nor demand that she eat, but offers support by agreeing to "be there if needed", e.g., to warm the food. (B and C) are arguing with the client's delusions, and (B) asks "why" which is usually not a good question for a psychotic client. (D) has nothing to do with the actual problem; i.e., the problem is not the diet (she thinks any food given to her is poisoned.) Correct Answer(s): A

37. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make? A) Did you really believe you were Jesus Christ? B) I think you're getting well. C) Others have had similar thoughts when under stress. D) Why did you think you were Jesus Christ?

(C) offers support by assuring the client that others have suffered as he has (also the principle on which Alcoholics Anonymous acts). (A) is belittling. (B) is making an inappropriate judgment. You may have narrowed your choices to (C and D). However, you should eliminate (D) because it is a "why" question, and the client does not know why! Correct Answer(s): C

A nurse encourages a client to join a self-help group after being discharged from a mental health facility. What is the purpose of having people work in a group? 1 Support 2 Confrontation 3 Psychotherapy 4 Self-awareness

1 Members of a self-help group share similar experiences and can provide valuable understanding and support to one other. Although confrontation and self-awareness may occur, these are not the primary purposes of self-help groups. Self-help groups provide an opportunity for people to interact, not to engage in professional psychotherapy.

What does a public health nurse expect to encounter when working with families raised in a culture of poverty? 1 Powerlessness relative to changing their situation 2 Willingness to delay gratification 3 Optimism about improving their lifestyle 4 Shame because of their inadequacy as parents

1 Powerlessness is a characteristic feeling among people in the culture of poverty, which tends to erode their hope for change. People in the culture of poverty usually require immediate gratification because they do not have enough faith in the future to delay gratification. Pessimism, not optimism, about changing a lifestyle is more common in these families. There is not sufficient evidence to indicate that poor people feel shame for their situation or that they are inadequate parents.

For which adverse effect should the nurse continually assess a client who is receiving valproic acid (Depakene)? 1 Yellow sclerae 2 Motor restlessness 3 Ringing in the ears 4 Torsion of the neck

1 Yellow sclerae are a sign of jaundice; pancreatitis and hepatic failure are life-threatening adverse effects of valproic acid (Depakene). The client must have frequent liver function tests. Motor restlessness (akathisia) is associated with antipsychotic drugs. Ringing or buzzing in the ears (tinnitus) is associated with aspirin. Torsion of the neck (torticollis) due to contracted cervical muscles is associated with antipsychotic drugs.

A 25-year-old woman is seeking outpatient counseling after thinking about suicide. The nurse realizes that there some factors place individuals at a higher risk for suicide. Which of these factors increases the risk for suicide? Select all that apply. 1 Impulsivity 2 Panic attacks 3 Unemployment 4 Religious beliefs 5 Substance abuse 6 Sense of responsibility to family

1235 Impulsivity, panic attacks, unemployment, and substance abuse have all been linked with an increased risk for suicide. A sense of responsibility to family and religious beliefs are considered protective factors that may lessen the risk of suicide.

A client is prescribed a monoamine oxidase inhibitor. The nurse teaches the client about what foods to avoid when taking this medication. Select all that apply. 1 Aged cheese 2 Fresh fish 3 Citrus fruits 4 Ripe avocados 5 Delicatessen meats

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A client comes to the mental health clinic for treatment of a phobia of large dogs. The nurse should anticipate that this client will demonstrate: 1 Fear of discussing the phobia 2 Resentment toward the feared object 3 Inadequate impulse control when threatened 4 Distortion of reality when discussing the phobia

1A discussion of the feared object will trigger an emotional response to the object. Extreme fear is more of a problem than resentment. Clients with phobias generally have rigid impulse control. Distortion of reality is not a problem for a client with a phobia.

A client is found to have a conversion disorder. What is the typical reaction by the client to the physical symptom? 1 Anger 2 Apathy 3 Anxiety 4 Agitation

2 Development of the symptom is an unconscious method of reducing anxiety. Because the symptom is meeting this need, it does not create anxiety itself but is passively accepted (la belle indifférence). There is no anger or agitation; symptoms are passively accepted. There is no anxiety; the conflict is resolved by the physical symptom.

A nurse who is assessing a recently hospitalized client with a diagnosis of opioid addiction should look for signs of withdrawal. What are these signs? Select all that apply. 1 Seizures 2 Yawning 3 Drowsiness 4 Constipation 5 Muscle aches

25Yawning and muscle aches are clinical manifestations of opioid withdrawal, which occurs after cessation or reduction of prolonged moderate or heavy use of opioids. Seizures do not occur with opioid withdrawal. Insomnia, not drowsiness, occurs with opioid withdrawal. Diarrhea, not constipation, occurs with opioid withdrawal.

A client who was sexually assaulted 3 hours ago comes to the emergency department of the hospital. The priority is for the staff to help the client feel: 1 Loved 2 Believed 3 Protected 4 accepted

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A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the preceding month. Of which level of suicidal behavior is the client's behavior reflective? 1 Threats 2 Ideation 3 Attempts 4 Gestures

4 A suicidal gesture involves superficial, nonlethal injuries; the client has no intent to die as a result of the injuries. A suicidal threat is a person's verbal statement of intent to commit suicide; there is no action. Suicidal ideation is a person's thoughts regarding suicide; there is no definitive intent or action expressed. A suicide attempt is an actual implementation of a severe self-injurious act; there is an attempt to cause serious self-harm or death.

What is an appropriate behavior modification goal for a client with anorexia nervosa? 1 Eating every meal for a week 2 Attending group therapy every day 3 Talking about food for 1 hour a day 4 Gaining 1 lb of weight a week

4 A goal is focused on where the client should be after certain actions are taken; this client needs to gain weight. Forcing the client to eat every meal for a week may set up a struggle between the client and the nurse; the focus of care should not be on the actual intake of food. Behavior modification techniques work much better than group therapy; anorexic clients lack insight and will focus on food, not eating. Anorexic clients talk freely about food; this is not therapeutic.

A nurse is caring for several extremely depressed clients. The nurse determines that these clients seem to do best in settings where they have: 1 Multiple stimuli 2 Varied activities 3 Opportunities for decision-making 4 Simple daily routines

4 Depression is usually both emotional and physical, so a simple daily routine is the least stressful and least anxiety producing. Too many stimuli increase anxiety in a depressed client. A depressed client has limited interest in any activity; offering many may increase anxiety. An extremely depressed client may be incapable of making even simple decisions.

According to Erikson, a person's adjustment to the period of senescence will depend largely on the adjustment the individual made to the earlier developmental stage of: 1 Trust versus mistrust 2 Industry versus inferiority 3 Identity versus role confusion 4 Generativity versus stagnation

4 Erikson theorized that how well people adapt to the current stage depends on how well they adapted to the stage immediately preceding it—in this instance, adulthood. Although Erikson believed that the strengths and weaknesses of each stage are present in some form in all succeeding stages, their influence decreases with time.

What is the most therapeutic nursing intervention to help a late-middle-aged individual cope with the emotional aspects of aging? 1 Focusing on the individual's past experiences 2 Having the individual attend lectures on aging 3 Encouraging the individual to focus on his or her career 4 Assisting the individual with plans for the future

4 Helping an individual maintain an interest in the future is therapeutic. It is forward looking and fosters a positive attitude. Focusing on the individual's past experiences is appropriate for an older adult, not a late-middle-aged adult. Lectures may or may not include emotional aspects of aging; also, the client should express an interest in this subject. Encouraging the individual to focus on his or her career does not address concerns about the future.

A young adolescent is found to have anorexia nervosa. The nurse understands that the anorexia nervosa was probably precipitated by: 1 The acting out of aggressive impulses, resulting in feelings of hopelessness 2 An unconscious wish to punish a parent who tries to dominate the adolescent's life 3 The inability to deal with being the center of attention in the family and a desire for independence 4 An inaccurate perception of hunger stimuli and a struggle between dependence and independence

4 Inaccurate perception of hunger stimuli and a struggle between dependence and independence are theoretical explanations for the development of anorexia nervosa. Acting-out and the wish to punish a domineering parent do not play a role in the development of anorexia nervosa. The inability to be the center the family's attention has not been correlated with anorexia nervosa.

While admitting a confused 80-year-old client to the mental health unit, the nurse recalls that one factor associated with the aging process is: 1 Changing of personality 2 Lowering of intelligence 3 Diminution of long-term memory 4 Slowing of responses

4 Neurological responses are slowed because of reduced sensory-receptor sensitivity. Excluding pathological processes, the personality will be consistent with that of earlier years. There is no loss of intellectual ability unless there is a pathological problem. Short-term, not long-term, memory is reduced because of a shortened attention span, delayed transmission of information to the brain, and perceptual deficits.

A female client with obsessive-compulsive disorder has become immobilized by her elaborate handwashing and walking rituals. The nurse recalls that the basis of obsessive-compulsive disorder is often feelings of: 1 Anger and hostility 2 Embarrassment and shame 3 Hopelessness and powerlessness 4 Anxiety and guilt

4 Ritualistic behavior seen in this disorder is aimed at controlling feelings of anxiety and guilt by maintaining an absolute set pattern of action. Although the person with an obsessive-compulsive disorder may be angry and hostile, the feelings of anger and hostility do not precipitate the rituals. Although the person with an obsessive-compulsive disorder may be embarrassed and ashamed by the ritual, the basic feelings precipitating the rituals are usually anxiety and guilt.

Which assessment finding alerts the nurse to stop administering haloperidol (Haldol) to a client until further laboratory work is done? 1 Grimacing 2 Shuffling gait 3 Photosensitivity 4 Yellow sclerae

4 Yellow sclerae is a sign of jaundice, indicating an increase of liver enzymes, which may be irreversible even if drug therapy is discontinued. Although grimacing may be a sign of a serious side effect, it may also just be a behavioral response of the disorder; the nurse should notify the practitioner rather than withhold the drug. Shuffling gait is a Parkinson-type symptom that can be reversed with treatment; continuation of the medication is permitted. Photosensitivity is not a problem as long as the client is cautioned to stay out of the sun.

A client is admitted to the hospital with a diagnosis of depression. What clinical manifestations of depression does the nurse expect when assessing this client? 1 Flight of ideas 2 Suspicion of others 3 Intrusive social behaviors 4 Psychomotor retardation

4Both thought and motor activity, which require physical and psychic energy, are commonly slowed when someone is depressed. Flight of ideas is associated with manic behavior because it requires psychic energy. Suspicion is associated with paranoid ideation and is less common with depression. Intrusive social behaviors are associated with manic behavior.

What characteristic of the environment is most therapeutic for clients with the diagnosis of bulimia nervosa? 1 Controlling 2 Empathetic 3 Focused on food 4 Based on realistic limits

4Realistic guidelines reduce anxiety, increase feelings of security, and increase adherence to the therapeutic regimen. A controlling environment sets up a power struggle between these clients and the nurse. These clients need realistic rules and regulations that they identify as helpful, not as empathy. Focusing on food is not therapeutic as it may result in a power struggle between these clients and the nurse.

A nurse is caring for a client with a diagnosis of conversion disorder manifesting as paralysis of the legs. Which is the most therapeutic nursing intervention? 1 Encouraging the client to try to walk 2 Explaining to the client that there is nothing wrong 3 Helping the client follow through with the physical therapy plan 4 Avoiding focusing on the client's physical symptoms

4The physical symptoms are not the client's major problem and therefore should not be the focus of care. This is a psychological problem, and the focus should be in this domain. Encouraging the client to try to walk is focusing on the physical symptom of the conflict; the client is not ready to give up the symptom. The disorder operates on an unconscious level but is very real to the client; this response denies feelings. Psychotherapy, not physical therapy, is needed at this time.

A recently hired nurse is caring for several clients on a mental health unit at a local community hospital. The nurse manager is evaluating the nurse's performance. What situation indicates that the nurse-client boundaries of the recently hired nurse are appropriate? 1 The nurse is often busy doing other tasks when the client and nurse are scheduled for a counseling session. 2 A client enters the therapeutic group late with the nurse's permission even though group rules say that this is not allowed. 3 A client's overall behavior is significantly more independent and demonstrates higher function on the days that the nurse is not working. 4 The nurse shares with the entire treatment team vital information the client disclosed in a private session.

4 The nurse is part of the treatment team and must share vital information with its members. When the nurse is underinvolved in the nurse-client relationship, respect and trust, which are necessary for therapy, do not develop. The nurse must not place other responsibilities over the commitment made to the client. A nurse who becomes overinvolved in the nurse-client relationship may bend the rules for a specific client. This is detrimental to that client and other clients who see the preferential treatment. A nurse who becomes overinvolved in the nurse-client relationship may also foster regressive behaviors that make the client more dependent.

A client's severe anxiety and panic are often considered "contagious." What action should be taken when a nurse's personal feelings of anxiety are increasing? 1 Refocusing the conversation to more pleasant topics 2 Saying to the client, "Calm down. You're making me anxious, too." 3 Remaining quiet so personal feelings of anxiety do not become apparent to the client. 4 Saying, "Another staff member is coming in. I'll leave and come back later."

4 The nurse who is anxious should leave the situation after ensuring continuity of care; the client will be aware of the nurse's anxiety, and the nurse's presence will be nonproductive and nontherapeutic. The client will probably sense the nurse's anxiety through nonverbal channels, if not through verbal responses. Refocusing and asking the client to calm down both meet the nurse's need; this response may make the client feel guilty that something was said that upset the nurse. The client will be aware of the nurse's anxiety, which will increase the client's own anxiety.

One day a nurse sits down by a depressed client's bed and says, "I'll be spending some time with you today." The client responds, "Go talk to someone else. They all need you more." What is the most therapeutic response by the nurse? 1 "Why do you want me to go?" 2 "I'll go, but I'll be back tomorrow." 3 "Don't you think that you're important, too?" 4 "I'll be spending the next half hour with you."

4 The nurse who spends time with the client conveys a feeling of importance and helps build the client's self-esteem. The response "Why do you want me to go?" places the client on the defensive and does not respond to the feelings of worthlessness communicated by the client. The response "I'll go, but I'll be back tomorrow" implies agreement with the client's implied statement that the client is not worthy; the nurse should stay to convey a sense of self-worth to the client. The response "Don't you think that you're important too?" may be too direct and may precipitate a no in reply. The client will respond better to actions than to words.

What is the most difficult initial task in the development of a nurse-client relationship? 1 Remaining therapeutic and professional 2 Being able to understand and accept a client's behavior 3 Accepting responsibility for identifying and evaluating the real needs of a client 4 Developing an awareness of self and the professional role in the relationship

4 The nurse's major tool in mental health nursing is the therapeutic use of self. Mental health nurses must learn to identify their own feelings and understand how they affect the situation. Although remaining therapeutic and professional and being able to understand and accept a client's behavior may be difficult, an awareness of self is still the most difficult part of developing a nurse-client relationship. Accepting responsibility for identifying and evaluating the real needs of a client implies that the nurse is working alone in caring for the client.

A client on the psychiatric service is pacing around the unit at a moderate rate and looking to either side of the hall. What is the most appropriate intervention by the nurse? 1 Warning the client that if the pacing does not stop a privilege will be removed 2 Approaching the client and recommending the performance of relaxation exercises 3 Allowing the client to continue pacing the hall and watching carefully from a distance 4 Talking with the client to assess the meaning of the behavior

4 The nurse's observations need to be validated with the client. Warning the client that if the pacing does not stop a privilege will be removed is punitive and threatening. The client's behavior indicates a moderately high level of anxiety; relaxation techniques will probably be unsuccessful at this time. Allowing the client to continue pacing the hall and watching carefully from a distance may be unsafe. Pacing indicates rising anxiety and agitation; early intervention is essential.

The nurse manager hears a conversation between a nurse and a client that is focused on the details of their impending divorces. What is the nurse manager's response? 1 Waiting until the conversation ends and then telling the nurse that such topics must be discussed in strict privacy to ensure client confidentiality 2 Immediately explaining to both nurse and client that such conversations are inappropriate and that the nurse's assignment will be changed 3 Waiting until shift report and using that opportunity to discuss appropriate nurse-client boundaries with the attending nursing staff 4 Immediately asking to speak to the nurse privately and stating that sharing such personal information is nontherapeutic and not tolerated

4 The nurse-client relationship should always remain client focused. Discussing personal issues with the client, even in an attempt to share similar experiences, is nontherapeutic and should be discussed immediately by the nurse's supervisor. Although the ease with which this conversation was overheard does raise concerns about the nurse's understanding of the client's right to confidentiality and privacy, there is a greater issue that needs immediate attention and should be addressed immediately. The nurse's management of the nurse-client relationship should be discussed privately. It may not be necessary to change the assignment. Although it may be useful to reinforce information on privacy with the entire staff, the situation requires an immediate private discussion between the nurse and the nurse manager to satisfactorily address the problem for the individual nurse.

The nurse is caring for a client who has attempted suicide. What is the most desirable short-term client outcome during this crisis situation? 1 Strengthening coping skills 2 Learning problem-solving techniques 3 Recognizing why suicide was attempted 4 Establishing a no-suicide contract

4 The primary goal is to keep the client safe. A no-suicide contract secures the client's agreement not to attempt suicide for a specified period and to seek help when suicidal ideas occur. Improving the client's coping skills is part of the treatment plan after the immediate crisis has been controlled. Teaching problem-solving is part of the long-range treatment plan after the immediate crisis is controlled.

A client is admitted with a conversion disorder. What is the primary nursing intervention? 1 Talking about the physical problems 2 Explaining how stress caused the physical symptoms 3 Focusing on the client's concerns regarding the symptoms 4 Exploring ways to verbalize feelings

4 The priority is getting the client to express feelings appropriately rather than through the use of physical symptoms. Focusing on symptoms will encourage their use by the client. An expression of feelings, not an intellectual understanding of the cause of the symptoms, is required. Avoidance of feelings resulted in the symptoms. Clients with a conversion disorder are rarely concerned about the associated physical problem; this is known as la belle indifférence.

Which psychotherapeutic theory uses hypnosis, dream interpretation, and free association as methods to release repressed feelings? 1 Behaviorist model 2 Psychobiologic model 3 Social-interpersonal model 4 Psychoanalytic mode

4 The psychoanalytic model studies the unconscious and uses the strategies of hypnosis, dream interpretation, and free association to encourage the release of repressed feelings. The behaviorist model holds that the self and mental symptoms are learned behaviors that persist because they are consciously rewarding to the individual; this model deals with behaviors on a conscious level of awareness. The psychobiologic model views emotional and behavioral disturbances as stemming from a physical disease; abnormal behavior is directly attributed to a disease process. This model deals with behaviors on a conscious level of awareness. The social-interpersonal model affirms that crucial social processes are involved in the development and resolution of disturbed behavior; this model deals with behavior on a conscious level of awareness.

A nurse at the crisis intervention center asks a new female client, who has come because her husband is planning a divorce, her reasons for seeking help. The client responds by describing her first meeting with her husband, when they were both teenagers. What is the most therapeutic response by the nurse? 1 "You're avoiding talking about the divorce." 2 "What does this have to do with your situation now?" 3 "Would you like to tell me more about the early years?" 4 "And now your husband is asking for a divorce."

4 The response "And now your husband is asking for a divorce" brings the client back to the current concern; in crisis therapy time is limited, and refocusing helps the client use it in the most therapeutic manner. "You're avoiding talking about the divorce" is too pointed; although it is important to focus on reality, it should be done in a manner that does not belittle the client. "What does this have to do with your situation now?" is too blunt; the aim is to refocus the client on the current problem without being demeaning. "Would you like to tell me more about the early years?" encourages discussion of material not directly related to the crisis.

. A newly admitted client quietly listens to a nurse's explanation of the services and activities available on the mental health unit. When the nurse is finished, the client looks around and says, "So this is where they keep the crazies." What is the most appropriate initial response by the nurse? 1 "These people are emotionally ill, not crazy." 2 "Some people feel that way. Let's talk about mental health." 3 "Do you want me to explain the purpose of a mental health unit?" 4 "Are you feeling that a person has to be crazy to need mental health services?"

4 The response "Are you feeling that a person has to be crazy to need mental health services?" addresses the client's misconceptions about mental health services and the specific fear of being "crazy." The response "These people are emotionally ill, not crazy" ignores the feelings behind the client's statement and focuses on facts. Acknowledging that some people feel that way and offering to talk about mental health or asking whether the client wants the nurse to explain the purpose of a mental health unit ignores the feelings behind the client's statement and focuses on facts.

The nurse tells a client that talking with the staff members is part of the therapy program. The client responds, "I don't see how talking to you can possibly help." What is the most appropriate response by the nurse? 1 "I can see how you might feel that way now, but I hope you'll change your mind." 2 "You'll never know whether or not it's helpful unless you're willing to give it a try." 3 "The one-on-one relationship has proved helpful for others, and you should give it a try." 4 "I hope I'll be able to help you sort out your thoughts and feelings so you can understand them better."

4 The response "I hope I'll be able to help you sort out your thoughts and feelings so you can better them better" is optimistic and supportive and clarifies the purpose of the relationship. The statement "I can see how you might feel that way now, but I hope you'll change your mind" diminishes the client's response and sets up a challenge; it does not foster a therapeutic relationship. The statement "You'll never know whether or not it's helpful unless you're willing to give it a try" diminishes the client's response and sets up a challenge; it does not foster a therapeutic relationship. The statement "The one-on-one relationship has proved helpful for others, and you should give it a try" diminishes the client's response and sets up a challenge; it does not foster a therapeutic relationship. `

One morning a client with the diagnosis of acute depression says, "God is punishing me for my past sins." What is the best response by the nurse? 1 "Why do you think that?" 2 "Do you believe that God is punishing you for your sins?" 3 "If you feel this way, you should talk to your spiritual advisor." 4 "You sound very upset about this.

4 The response focuses on the client's feelings rather than the statement, and it serves to open channels of communication. "Why do you think that?" asks the client to decide what is causing the feelings; most people are unable to explain why they feel as they do. "Do you believe that God is punishing you for your sins?" simply echoes the client's statement and does not reflect feelings or stimulate further communication. "If you feel this way, you should talk to your spiritual advisor" does nothing to stimulate further communication; in fact, it tells the client to talk about the feelings with someone else.

What statement by a male client during a yearly physical examination indicates to a nurse that the client may have a sexual arousal disorder? 1 "I have no interest in sex." 2 "I climax almost before we even get started." 3 "It takes forever before I finally have an orgasm." 4 "I don't get hard during sex anymore."

4 The statement "I don't get hard during sex anymore" indicates a sexual arousal disorder, which is a partial or complete failure to achieve a physiologic or psychological response to sexual activity. The statement "I have no interest in sex" may indicate a sexual desire disorder in which the individual has deficient or absent interest in, or extreme aversion to and avoidance of, sexual activity. "I climax almost before we even get started" and "It takes forever before I finally have an orgasm" are both indicative of an orgasmic disorder, which is a delay in or absence of an orgasm or premature ejaculation.

A client tells a mental health nurse about hearing a man speaking from the corner of the room. The client asks whether the nurse hears him, too. What is the nurse's best response? 1 "What is he saying to you? Does it make any sense?" 2 "No one is in the corner of the room. Can't you see that?" 3 "Yes, I hear him, but I can't understand what he's saying." 4 "No, I don't hear him, but it probably upsets you to hear him."

4 The statement "No, I don't hear him, but it probably upsets you to hear him" points out reality, recognizes the client's feelings, and prevents the nurse from becoming involved in the client's hallucination. The response "What is he saying to you? Does it make any sense?" is nontherapeutic; it supports and focuses on the hallucination. The response "No one is in the corner of the room. Can't you see that?" is an attempt to argue the client out of feelings by denying they exist. The response "Yes, I hear him, but I can't understand what he is saying" is nontherapeutic; it supports and focuses on the hallucination.

A client with a diagnosis of paranoid schizophrenia tells the nurse, "Foreign agents are talking to me, and they say they're going to get me eventually." What is the most therapeutic response by the nurse? 1 "What else are they saying to you?" 2 "Do you really believe that they'll get you eventually?" 3 "Foreign agents are not allowed in the hospital, so you're safe." 4 "These thoughts are frightening, but I can't hear the voices."

4 The statement "These thoughts are frightening, but I can't hear the voices" is therapeutic because support is offered and reality is presented in a nonthreatening manner. "What else are they saying to you?" is inappropriate because it reinforces the client's delusion. "Do you really believe they'll get you eventually?" is demeaning; the delusions are real to the client. "Foreign agents aren't allowed in the hospital, so you're safe" is an empathetic statement, but it is also false reassurance because the client believes that the threat is real.

A nurse is interviewing a client in the mental health clinic. Which statement by the client indicates an irreversible adverse response to long-term therapy with an antipsychotic medication? 1 "My mouth is always dry." 2 "I can't seem to sleep at night." 3 "I don't have much of an appetite." 4 "My tongue seems to move by itself."

4 The tongue's moving by itself is characteristic of tardive dyskinesia, an irreversible, antipsychotic, drug-induced neurological disorder. Dry mouth is an anticholinergic-type side effect that is not considered serious. This drug will cause sedation, not insomnia. Lack of an appetite is unrelated to antipsychotic medications.

When leading the first session of a newly formed group of clients in a mental health clinic, the nurse notes that group members frequently assume self-serving roles. The nurse understands that: 1 Some group members will need to be placed in another group. 2 Certain group members may be emerging to control attention seekers. 3 The group is attempting to reconcile conflicting viewpoints among its members. 4 Early group development involves these behaviors.

4 These behaviors are a necessary phase of group development because they help members discover what they can expect from the leader and other members. It is inappropriate to assume at the first meeting that some clients will need to be switched to another group. Group factions are unlikely to emerge in the first session; moreover, factions seldom emerge to control disruptive group behavior. The group has not yet developed to the phase of reconciling conflict; conflict resolution and management occur only in operating groups.

A nurse in the mental health unit is working with a group of adolescent girls with the diagnosis of anorexia nervosa. The nurse recalls that the major health complication associated with intractable anorexia nervosa is: 1 Endocrine imbalance causing amenorrhea 2 Decreased metabolism causing cold intolerance 3 Glucose intolerance resulting in protracted hypoglycemia 4 Cardiac dysrhythmias resulting in cardiac arrest

4 These clients have severely depleted levels of potassium and sodium because of the starvation diet and energy expenditure; these electrolytes are necessary for adequate cardiac function. Although endocrine imbalance resulting in amenorrhea, slowed metabolism resulting in cold intolerance, and glucose intolerance resulting in protracted hypoglycemia may occur, they are not the major health problem.

An adolescent with the diagnosis of antisocial personality disorder is admitted to the hospital after ingesting 20 tablets of an anxiolytic. When obtaining the client's history, the nurse learns that there was an arrest for drug use and that the client is out on bail. During visiting hours the nurse discovers the client and visitors smoking marijuana in the hall. When confronted, the client responds, "I'm celebrating. Didn't you hear? I went to trial today and just got put on probation." What is the best response by the nurse? 1 "You were lucky you just got probation, so don't get right back into trouble." 2 "I understand your relief about the trial, but smoking pot is against the rules." 3 "It's important that you and your friends join the other visitors in the dayroom." 4 "If you can't follow the rules against drug use on the unit, your visiting privileges will be canceled."

4 This client needs firm, realistic limits set on behavior. The statement "If you can't follow the rules against drug use on the unit, your visiting privileges will be canceled" permits the client to make the choice and clearly states the consequences of behavior. Clients with this diagnosis do not learn from past errors. The response "I understand your relief about the trial, but smoking pot is against the rules" states the limits but does not inform the client of the consequences if the limits are broken. Clients with the diagnosis of antisocial personality disorder do not care about rules. The client and visitors will probably refuse to socialize with other clients and visitors.

A nurse who plans to care for a client with an obsessive-compulsive disorder should understand that the client's personality is usually characterized by: 1 Marked emotional maturity 2 Elaborate delusional systems 3 Rapid, frequent mood swings 4 Doubts, fears, and indecisiveness

4 This disorder is characterized by anxiety and minor distortions of reality. The anxiety results in an inability to reach a decision because all alternatives are threatening. Part of emotional maturity is the ability to relate to people, and these clients have difficulty in this area. Elaborate delusions are indicative of severe emotional illness, not an anxiety disorder. Rapid mood swings are indicative of a mood disorder.

The nurse is caring for a client experiencing a crisis. What role is most important for the nurse to assume when providing therapeutic crisis intervention? 1 Passive listener 2 Friendly adviser 3 Participant observer 4 Active participan

4 To intervene in a crisis the nurse must assume a direct, active role because the client's ability to cope is lessened and help is needed to problem-solve. Being a passive listener is insufficient to help the client. Being a friendly adviser can blur the boundaries between a professional and a social relationship. The role of the nurse should not include giving advice. Being a participant observer is insufficient to help the client.

Which assessment question will provide the best information regarding a client's risk for waking in the night and interrupted sleep related to lifestyle choices? 1 "Do you consider yourself a deep sleeper?" 2 "Do you adhere to a regular bedtime routine?" 3 "Do you keep the television on when you're falling asleep?" 4 "Do you smoke cigarettes, cigars, or a pipe?"

4 Tobacco use leads to nicotine addiction. An addiction to nicotine can result in interrupted sleep as the nicotine level declines through the night; the individual is awakened with mild withdrawal symptoms. Lack of a bedtime routine and the presence of environmental noise will likely cause difficulty in falling asleep rather than in staying asleep. An individual who is a deep sleeper will likely have difficulty awakening rather than staying asleep.

Which statement demonstrates that a psychiatric nurse has fostered the most therapeutic nurse-client relationship? 1 "Nurses and clients must develop a therapeutic relationship if appropriate mental and physical care is to be provided." 2 "Mental health is best achieved and maintained when the nurses and the clients exhibit respect and caring for each other." 3 "Without a mutually satisfying relationship between nurse and client, the process needed to maximize mental and physical wellness is greatly hindered." 4 "My clients and I are partners in the planning that helps meet their physical and mental health needs."

4 Today's nurse-client relationship is one that demonstrates the nurse's clinical competence while recognizing the client's right to self-determination in decisions affecting both physical and mental health. Although the development of a true therapeutic relationship is a goal, when that is not achievable because of the client's mental health status, appropriate nursing care is still achievable. Although the demonstration of mutual respect and caring are basic elements, other factors also have an impact on the formation of a therapeutic nurse-client partnership. A truly therapeutic nurse-client relationship provides satisfaction for both nurse and client; that may not be achievable because of the client's mental health status. The nursing process can still provide care that strives to meet client outcomes that are reflective of their potential for both physical and mental wellness.

A client with a known history of opioid addiction is treated for multiple stab wounds to the abdomen. After surgical repair the nurse notes that the client's pain is not relieved by the prescribed morphine injections. The nurse realizes that the failure to achieve pain relief indicates that the client is probably experiencing the phenomenon of: 1 Habituation 2 Physical addiction 3 Psychological dependence 4 Tolerance

4 Tolerance is a phenomenon that occurs in addicted individuals in which increasing amounts of the drug of addiction are needed to satisfy need; the client should receive adequate analgesia after surgery. Drug habituation is a mild form of psychological dependence; the individual develops a habit of taking the substance. A physical addiction is related to biochemical changes in body tissues, especially the nervous system. The tissues come to require the substance for usual function. Psychological dependence is emotional reliance on the substance to maintain a sense of well-being.

The serum lithium blood level of a client with a mood disorder, manic episode, is 2.3 mEq/L. What should the nurse expect when assessing this client? 1 Elevation in mood 2 Nausea, thirst, and fine hand tremor 3 Decrease in manic signs and symptoms 4 Vomiting, diarrhea, and decreased coordination

4 Vomiting, diarrhea, and decreased coordination are reflective of lithium toxicity. During the active phase of a manic episode a lithium level of 2.3 mEq/L is more than the therapeutic range of 0.8 to 1.4 mEq/L. An improvement in mood may occur when the therapeutic level is approached early in lithium therapy. Nausea, thirst, and fine hand tremor are common early side effects of lithium treatment. They are not related to lithium toxicity, which is indicated by a 2.3 mEq/L lithium level. During the acute phase of mania the therapeutic serum level of lithium should be between 0.8 and 1.4 mEq/L. The maintenance therapeutic serum level ranges from 0.4 to 1.0 mEq/L. A reduction in symptoms is expected when the therapeutic level of lithium is reached.

A client was recently given a diagnosis of a manic episode of a bipolar I disorder. What activity is most therapeutic for this client at this time? 1 Doing a craft project 2 Playing a game of table tennis 3 Playing cards with another patient 4 Walking around the unit with a nurse

4 Walking allows the client to burn excess energy in a safe, acceptable activity. A one-on-one activity demonstrates that the nurse cares and may allow the nurse to verbally interact with the client. A quiet activity such as a craft project for a person who is hyperactive is unrealistic and would be frustrating for the client. A game of table tennis would be too stimulating and competitive, both of which may increase anxiety. A hyperactive client does not have the ability to be quiet and focus on a card game.

A nurse determines that a client is pretending to be ill. What does this behavior usually indicate? 1 Psychosis 2 Lack of contact with reality 3 Use of conversion defenses 4 Malingering

4 When an individual consciously pretends to have an illness with no physical basis, it is called malingering. People who are psychotic experience delusions, hallucinations, and disorganized thoughts, speech, or behavior. A person out of contact with reality is unable to pretend to be ill. The use of conversion defenses is not a conscious act.

The nurse is scheduled to be the co-leader of a therapy group being formed in the mental health clinic. When planning for the first meeting, it is of primary importance that the nurse consider the: 1 Number of clients in the group 2 Diagnoses of the clients being included 3 Socioeconomic status of the clients in the group 4 Needs of the clients being included

4 When planning a group, the nurse must ensure that clients have similar needs to promote relationships and interactions; diverse needs do not foster group process. Although important, the number of clients is not a primary consideration. Behavior and needs, rather than diagnoses, are of primary importance. The socioeconomic status of the clients in the group has little effect on group process.

A depressed client has feelings of failure and a low self-esteem. In what activity should the client initially be encouraged to become involved? 1 Joining other clients in playing a board game 2 Singing in a karaoke contest to be held at the end of the week 3 Selecting the movie to be played during the evening recreation period 4 Assisting a staff member in working on the monthly bulletin board

4 Working on the bulletin board with staff members involves minimal energy and decision-making and is the least threatening activity. Playing a board game is too stressful at this time; it will be a better intervention when self-esteem improves and depression lessens. Singing karaoke is too stressful an activity because it requires energy and good self-esteem, which the client does not have at this time. Selecting a movie is too stressful at this time; it will be a better intervention when self-esteem improves and depression lessens.

Imipramine (Tofranil), 75 mg three times per day, is prescribed for a client. What nursing action is appropriate when this medication is being administered? 1 Telling the client that barbiturates and steroids will not be prescribed 2 Warning the client not to eat cheese, fermented products, and chicken liver 3 Monitoring the client for increased tolerance and reporting when the dosage is no longer effective 4 Having the client checked for increased intraocular pressure and teaching about symptoms of glaucoma

44 Glaucoma is one of the side effects of imipramine (Tofranil), and the client should be taught the symptoms. Tolerance is not an issue with tricyclic antidepressants such as imipramine. The other actions are true of monoamine oxidase inhibitors (MAOIs); imipramine is not an MAOI.

A client has been in the alcohol detoxification unit for 5 days. In the evening the client complains of numbness and tingling in the feet and legs. What is the most appropriate nursing intervention? 1 Massaging the client's legs with lotion 2 Emphasizing the need to rest and keep the legs elevated 3 Monitoring the progression of symptoms and assessing the pedal pulses frequently 4 Keeping the bed linens off the client's legs with a mechanical aid

44 Peripheral neuropathy is present, and keeping the bedclothes off the client's legs will limit tactile stimulation. The nurse may choose to monitor the progression of symptoms and assess the pedal pulses frequently, but these symptoms are not caused by impaired circulation; rather, they are the result of alcohol-induced peripheral neuropathy. Massaging the client's legs or having the client rest and elevate the legs will do little to relieve the discomfort or ease the neurological symptoms.

A 23-year-old woman is admitted to a psychiatric unit after several episodes of uncontrolled rage at her parents' home, and borderline personality disorder is diagnosed. While watching a television newscast describing an incident of violence in the home, the client says, "People like that need to be put away before they kill someone." The nurse concludes that the client is using: 1 Denial 2 Introjection 3 Sublimation 4 Projection

444Projection is the process of attributing one's thoughts about one's self to others. Denial involves pushing out of awareness one's own thoughts, wishes, or feelings that are unacceptable to one's own self. Introjection is the process of taking in someone else's values, beliefs, attitudes, or qualities. Sublimation is the channeling of unacceptable thoughts or feelings into acceptable activities.

A client with depression is to be given fluoxetine (Prozac). What precaution should the nurse consider when initiating treatment with this drug? 1 It must be given with milk and crackers to avoid hyperacidity and discomfort. 2 Eating cheese or pickled herring or drinking wine may cause a hypertensive crisis. 3 The blood level should be checked weekly for 3 months to monitor for an appropriate level. 4 The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks.

44Fluoxetine (Prozac) does not produce an immediate effect; nursing measures must be continued to reduce the risk for suicide. Consuming milk and crackers to help prevent hyperacidity and discomfort is not necessary. Avoiding cheese, pickled herring, and wine is a precaution taken with the monoamine oxidase inhibitors. Weekly blood level checks are not necessary with fluoxetine.

team approach is used to help a 6-year-old boy with attention deficit-hyperactivity disorder (ADHD). What behaviors indicate that the interventions have been effective? Select all that apply. 1 Is not inhibited by rules or routines 2 Has fun playing with toys by himself 3 Is no longer enuretic during the night 4 Has an increased attention span in school 5 Is able to wait his turn when in line with others

45 One characteristic of children with ADHD is the inability to remain focused on any activity; an increased attention span in school indicates that the child has improved. Other characteristics of children with ADHD are impulsivity, impatience, and the inability to delay gratification; the ability to wait for one's turn in line indicates that the child has improved. A lack of inhibition by rules or routines indicates that the child has not made sufficient progress and his behavior is still impulsive. Having fun playing with toys by himself indicates that the child has not made progress, because children should enjoy playing with peers at this age. A 6-year-old child usually does not experience nocturnal enuresis; there are no data to indicate that the child had enuresis.

A nurse is caring for a client with the diagnosis of schizophrenia. During assessment the nurse identifies both positive (type I) and negative (type II) signs and symptoms. Which clinical findings should the nurse document as positive? Select all that apply. 1 Anergy 2 Flat affect 3 Social withdrawal 4 Disorganized thoughts 5 Auditory hallucinations

45 Disorganized thoughts (e.g., derailment, tangentiality, illogicality, incoherence, and circumstantiality) are a positive sign of schizophrenia. Positive signs and symptoms, referred to as "florid psychotic symptoms," are related to alterations in thinking, speech, perception, and behavior. They usually respond to antipsychotic medications. Positive symptoms reflect an excess or distortion of function and include delusions, hallucinations, increased speech production with associations, and bizarre behavior. A lack of energy (anergy) is a negative symptom associated with schizophrenia. Negative symptoms reflect a lessening or loss of normal function. A lack of emotional expression (flat affect) is a negative sign associated with schizophrenia. Inadequate social skills leading to withdrawal and isolation are negative symptoms associated with schizophrenia.

. A client is receiving carbamazepine (Tegretol) for the treatment of a manic episode of bipolar disorder. What should the nurse include when planning client teaching about this medication? Select all that apply. 1 "You have to eat a low-sodium diet every day." 2 "You'll have to take a diuretic with this medication." 3 "You'll have to take this medication for the rest of your life." 4 "You may want to suck on hard candy when you get a dry mouth." 5 "We'll need to test your blood often during the first few weeks of therapy."

45 Sucking on hard candy or frequent rinsing may relieve a dry mouth, a side effect of carbamazepine. Carbamazepine can cause severe bone marrow depression in the early phase of therapy. Also, the drug level needs to be checked frequently to ensure a therapeutic level. A low-sodium diet is not required; nor is a diuretic. The client may or may not have to take the medication for life.

A family member brings a relative to the local community hospital because the relative "has been acting strange." Which statements meet involuntary hospitalization criteria? Select all that apply. 1 "My boss makes me so angry—he's always picking on me." 2 "I cry all the time; I'm just so sad." 3 "Since I retired I've been so depressed." 4 "I'd like to end it all with sleeping pills." 5 "The voices say I should kill all prostitutes."

45 The statement about ending it all is a suicide threat; it is a direct expression of intent without action. Likewise, the threat to harm others must be heeded. Confiding feelings of sadness or depression does not indicate that the client plans to self-harm or harm others. The statement about the boss reflects the client's feelings of anger and the cause but does not indicate a threat to self or others.

A client states, "I get down on myself when I make a mistake." In a cognitive therapy approach, which nursing interventions are most appropriate? Select all that apply. 1 Teaching the client relaxation exercises to diminish stress 2 Exploring with the client past experiences that have caused distress 3 Providing the client with mastery experiences designed to boost self-esteem 4 Encouraging the client to replace these negative thoughts with positive thoughts 5 Helping the client modify the belief that anything less than perfection is unacceptable

45Cognitive therapy seeks to find underlying self-defeating beliefs and replace them with more reality-based positive beliefs. It encourages the use of cognitive restructuring (cognitive reframing) through positive self-talk and a rational mindset. Teaching the client relaxation exercises to diminish stress reflects a behavioral approach. Exploring with the client past experiences that have caused distress is a psychoanalytical approach. Providing the client with mastery experiences to boost self-esteem is a behavioral approach.

A client who consented to electroconvulsive therapy (ECT) is being prepared for the second session. The client tells the nurse, "I've decided that I don't want this treatment." What is the best response by the nurse? 1 "It's too late to stop the treatment now." 2 "We'll discuss the advantages after the treatment." 3 "You need more than one treatment for it to be successful." 4 "I'll tell your psychiatrist that you don't want the treatment."

4A client has the right to revoke consent for treatment at any time; continuing treatment is a violation of the client's rights. "It's too late to stop the treatment now" is incorrect, and continuing with the treatment would be an act of battery. Teaching about the advantages and disadvantages of therapy should be conducted before, not after, the treatment; giving the client treatment without consent is an act of battery. A statement such as "You need more than one treatment for it to be successful" is considered coercion; continuation of treatment after the client's refusal would be an act of battery.

A client with a dissociative identity disorder is to be discharged after a 2-week hospitalization. The nurse, evaluating the effectiveness of the short-term therapy, expects the client to verbalize: 1 The ability to deal openly with feelings 2 That many of the personalities can be ignored 3 That the personalities serve no protective purpose 4 The need for long-term outpatient psychotherapy

4A dissociative identity disorder is a complex, multifaceted problem that requires long-term therapy to achieve integration of the personalities. Each personality has the ability to deal openly with feelings, but the personalities need to be integrated. None of the personalities can be ignored because their presence must be dealt with before integration can occur. The multiple personalities do serve a protective purpose. If they did not serve a protective purpose, they would be abandoned.

After counseling an older widowed client, a nurse concludes that the grieving process has been successfully completed when the client: 1 Talks about the deceased spouse at great length 2 Ignores the deceased spouse's less-than-perfect qualities 3 Decides to leave the deceased spouse's study as it was before the death 4 Is able to plan to start new relationships

4A healthy resolution helps the person move away from the old, safe, familiar relationship to establish new ones. Talking about the deceased spouse at great length is termed obsessional review; the mourner can talk of nothing else but the deceased and events surrounding the death. A reduction in obsessional review is a healthy sign. With a positive outcome to the grieving process, the mourner is able to see and accept the dead person's negative and positive qualities. Leaving the deceased spouse's study as it was before the death is an example of mummification, pathological outcome to the grieving process.

What clinical manifestation best indicates to the nurse that the mental status of a client with the diagnosis of schizophrenia, paranoid type, is improving? 1 Absence of mild to moderate anxiety 2 Development of insight into the problem 3 Decreased need to use defense mechanisms 4 Ability to function effectively in activities of daily living

4A person who can handle the activities of daily living and function in society is considered mentally stable. Some anxiety is necessary and unavoidable; anxiety causes problems when it is overwhelming for an extended period. Insight into one's problems is of no use if one is unable to function in society. Everyone uses defense mechanisms; the extent to which they are used helps determine mental health.

Windows in the recreation room of the adolescent unit have been found broken on numerous occasions. After a group discussion one of the adolescents provides sound evidence that another adolescent has broken them. What nursing action involves an assertive intervention? 1 Knocking on the door of the culprit's room and asking to talk about the situation 2 Confronting the culprit openly in the group and using a controlled voice while maintaining eye contact 3 Using a trusting approach and implying that the staff doubts the culprit's involvement but requests a written denial 4 Approaching the culprit when alone and, after making eye contact, inquiring about his involvement in these incidents

4A private confrontation with reported facts permits verification; a calm, direct manner is most assertive. Knocking on the door of the culprit's room and asking to talk about the situation places the adolescent, rather than the nurse, in control of the situation, which may progress to aggressive confrontation. Confronting the culprit openly in the group and using a controlled voice while maintaining eye contact is aggressive confrontation, not assertive intervention. Using a trusting approach and implying that the staff doubts the culprit's involvement but requesting a written denial is not assertive intervention; it is manipulation and is not truthful.

A married woman is brought to the emergency department of a local hospital. Her eyes are swollen shut, and she has a bruise on her neck. She reports that she is being beaten by her husband. How does the nurse expect the husband to behave when he arrives at the emergency department? 1 Fearful 2 Confused 3 Indifferent 4 Charming

4Abusers are often extremely charming to mask their abusive tendencies and convince the abused mate and others that change is possible. After an abusive episode there is often a "honeymoon" period because the tensions of the abuser have been released. Abusers mask their fears by becoming angry and aggressive. Abusers are not confused; they are manipulative of others. Abusers are rarely indifferent; they tend to be opinionated and demanding.

According to Erikson, what will happen to an individual who fails to master the maturational crisis of adolescence? 1 Interpersonal isolation 2 Rebellion against parental orders 3 Feelings of inferiority on comparing the self to others 4 Role confusio

4According to Erikson, adolescents are struggling with identity versus role confusion, struggling to find out who they are. If an adolescent is unsuccessful in this regard, role confusion may result. Industry versus inferiority is the developmental struggle of the school-aged child. This reflects part of the struggle for autonomy; it does not indicate failure to achieve the developmental task of adolescence. Adolescents tend to be group oriented, not isolated; they struggle to belong, not to escape. Developing intimacy is the developmental task for the young adult.

A resident in a nursing home recently immigrated to the United States from Italy. How does the nurse plan to provide emotional support? 1 By ensuring that the client understands American beliefs 2 By assisting the client in adjusting to the American culture 3 By correcting the client's misconceptions about appropriate health practices 4 By offering choices consistent with the client's heritage

4Adherence to a plan of care is enhanced by the nurse's providing choices consistent with the client's cultural beliefs and practices. The nurse's cultural or personal beliefs and biases should not influence or interfere with the implementation of appropriate care. Helping the client adjust to the American culture is not the priority at this time; care should be adapted to the client's needs and culture. The person's cultural practices should not be addressed unless they are detrimental to the person's health.

A constructive but lengthy method of confronting the stress of adolescence and preventing a negative and unhealthy developmental outcome is: 1 Adherence to peer standards 2 Sublimation through schoolwork 3 Development of dependence on parents 4 Role experimentation

4Adolescents learn about who they are by assuming and experiencing a variety of roles; experimentation results in the retention or rejection of behavior and roles. Adherence to peer standards is not constructive; it does not allow experimentation with a variety of roles. Sublimation is not constructive and delays and interferes with the successful completion of the struggle to formulate one's identity. Development of dependence on parents is not constructive; it does not allow the development of independence.

A nurse is counseling the spouse of a client who has a history of alcohol abuse. The nurse explains that people with a long history of alcohol abuse drink alcohol mainly because they: 1 Lack the motivation to stop 2 Have no other coping mechanism 3 Enjoy the associated socialization 4 Are dependent on it

4Alcohol causes both physical and psychological dependence; the individual needs the alcohol to function. Alcoholism is a disorder that entails physical and psychological dependence. The individual is unlikely to have other coping mechanisms; however, the individual needs to learn how to use other coping mechanisms more consistently and effectively. People with alcoholism usually drink alone or feel alone in a crowd; this is not the prime reason for their drinking.

What should the nurse do when an adolescent girl with the diagnosis of anorexia nervosa starts to discuss food and eating? 1 Listen to the client's list of favorite foods and secure these foods for her. 2 Use the client's current interest in food to encourage her to increase her food intake. 3 Let the client talk about food as long as she wants and limit discussion about her eating. 4 Tell the client gently but firmly to direct her discussion of food to the nutritionist.

4All food issues should be discussed with the nutritionist, thereby removing a potential source of conflict between the nurse and client. Listening to the client's list of favorite foods and securing these foods for her will accomplish little because the client's failure to eat is not based on food likes or dislikes. Using the client's current interest in food to encourage her to increase her food intake will increase the conflict between the nurse and client. Letting the client talk about food as long as she wants and limiting discussion about her eating may be self-defeating because a discussion of food will be the major focus of all nurse-client interactions.

A practitioner prescribes alprazolam (Xanax) 0.25 mg by mouth three times a day for a client with anxiety and physical symptoms related to work pressures. For what most common side effect of this drug should the nurse monitor the client? 1 Bradycardia 2 Agranulocytosis 3 Tardive dyskinesia 4 Drowsiness

4Alprazolam (Xanax), a benzodiazepine, potentiates the actions of γ-aminobutyric acid, enhances presympathetic inhibition, and inhibits spinal polysynaptic afferent pathways. Drowsiness, dizziness, and blurred vision are common side effects. Alprazolam may cause tachycardia, not bradycardia. Agranulocytosis is usually a side effect of the antipsychotics in the phenothiazine, not the benzodiazepine, group. Tardive dyskinesia occurs after prolonged therapy with antipsychotic medications; alprazolam is an antianxiety medication, not an antipsychotic.

A health care provider prescribes divalproex (Depakote). What does the nurse consider an appropriate indication for the use of this drug? 1 Control of acute agitation of schizophrenia 2 Treatment of the agitated phase of a paranoid state 3 Modification of the depressive phase of major depression 4 Management of manic episodes of bipolar disorder

4Although divalproex (Depakote) is an antiepileptic, it is used to control the manic phase of bipolar disorder. Divalproex is not the drug of choice for schizophrenia; nor is it used for agitated paranoid states. Divalproex is not used for major depression, except with a history of at least one manic episode or a family history of manic disorders.

A person mowing a lawn is badly disfigured by the lawnmower blade. According to Erikson's theory, which age at the time of injury will be associated with the greatest risk of long-term psychological effects? 1 35 years 2 55 years 3 70 years 4 11 years

4An 11-year-old child is generally in Erikson's stage of industry versus inferiority, which involves the mastery of skills; unfortunately, the child did not master the skill of lawnmowing. Also, the child will be entering adolescence (stage of identity versus confusion) when major physical and emotional changes occur in relation to how one is perceived by the self and by others. A 35-year-old adult is generally in Erikson's stage of intimacy versus isolation and therefore is less concerned about proving industriousness; a person of this age has usually moved through the stage of identity versus confusion. A 55-year-old adult is generally in the stage of generativity versus stagnation, is therefore less concerned about being industrious, and has moved through the stage of identity versus confusion. A 70-year-old adult is generally in Erikson's stage of ego integrity versus despair, is less concerned about becoming industrious, and has moved through the stage of identity versus confusion.

The nurse explains to a nursing assistant that behavior usually is viewed and accepted as normal if it: 1 Helps the person reduce the need for coping skills 2 Expresses the individual's feelings and thoughts accurately 3 Allows achievement of short-term and long-term goals by the individual 4 Fits within standards accepted by one's society

4An accepted practice in some parts of the world may well be considered abnormal behavior in others. Cultural context is necessary to understand behavior. Coping skills are behaviors that help people adapt to stress. Whether they are viewed as normal or not depends on their cultural context. Accurate expressions of feelings may take the form of behaviors considered abnormal. Behavior that is aggressive or destructive, even if it helps the client reach a goal, cannot be considered normal.

A male client is preparing to leave the hospital and return to college. When saying goodbye he hugs the nurse and kisses her on the cheek. What is the most appropriate response by the nurse? 1 Encourage him to visit periodically. 2 Hug the client in return. 3 Smile at the client but say nothing. 4 Wish him well with his future studies

4An explicit termination statement is most appropriate; offering an expression of well-wishes sets an optimistic, positive tone while maintaining the nurse-client relationship. A repeat of the physical contact should be avoided because it may precipitate anxiety in the client or be interpreted as a desire to change the relationship from professional to personal. Smiling and saying nothing may indicate acceptance of the physical exchange and blurs boundaries. Encouraging the client to visit periodically is nontherapeutic because it indicates an ongoing rather than a terminating relationship.

When planning care for an older client, the nurse remembers that aging has little effect on a client's: 1 Sense of taste or smell 2 Muscle or motor strength 3 Ability to remember recent events 4 Capacity to handle life's stresses

4An individual's ability to handle stress develops through experience with life; aging does not reduce this ability but often strengthens it. The senses of taste and smell are often diminished in the older individual. Muscle or motor strength is diminished in the older individual. Short-term memory is diminished in the older individual, whereas long-term memory remains strong.

A nurse leads an assertiveness training program for a group of clients. Which statement by a client indicates that the treatment has been effective? 1 "I know that I should put the needs of others before mine." 2 "I won't stand for it, so I told my boss he's a jerk and to get off my back." 3 "It's easier for me to agree up front and then do just enough so that no one notices." 4 "It annoys me when people call me 'sweetie,' so I told him not to do it anymore."

4Announcing that "sweetie" is annoying is an assertive statement; it clearly indicates what the problem is and sets limits on undesired behavior without being demeaning. Stating that she should put the needs of others before hers is nonassertive or passive and denies the individual's own needs and desires. Stating that she won't stand for someone else's behavior and calling the person a jerk is an aggressive statement that is demeaning and intimidating. Stating that it's easier for her to agree up front and then do just enough so no one notices is a passive-aggressive response that avoids direct, honest confrontation in favor of devious manipulation.

In conjunction with which classification of medication are trihexyphenidyl, biperiden (Akineton), and benztropine (Cogentin) often prescribed? 1 Anxiolytics 2 Barbiturates 3 Antidepressants 4 Antipsychotics

4Antipsychotics are used to control the extrapyramidal (parkinsonian) symptoms that often develop as a side effect of antipsychotic therapy. There is no documented use of anxiolytics with antianxiety agents because they do not have extrapyramidal side effects. Barbiturates do not have extrapyramidal side effects that respond to these drugs. Antiparkinsonian drugs usually are not prescribed in conjunction with antidepressants because antidepressants do not cause parkinsonian symptoms.

A practitioner prescribes haloperidol (Haldol) 10 mg by mouth twice a day for a client who is also receiving phenytoin (Dilantin) for control of epilepsy. When planning the client's care, the nurse considers that anticonvulsants may interact with haloperidol to: 1 Mask its therapeutic effect. 2 Interfere with its absorption. 3 Enhance its rate of metabolism. 4 Potentiate its central nervous system depressant effect.

4Antiseizure medications and haloperidol (Haldol) exert a synergistic central nervous system depressant effect. The effect is potentiated, not masked. Anticonvulsants do not affect the absorption of haloperidol. Anticonvulsants do not affect the metabolism of haloperidol.`

A young mother of three children, all born 1 year apart, has been hospitalized after trying to hang herself. The client is being treated with milieu therapy. The nurse understands that this therapeutic modality consists of: 1 Providing individual and family therapy 2 Using positive reinforcement to reduce guilt 3 Uncovering unconscious conflicts and fantasies 4 Manipulating the environment to benefit the client

4Any aspect of the treatment environment can be used to benefit the client in milieu therapy. Individual and family therapy are separate treatment modalities, not part of milieu therapy. Using positive reinforcement to reduce guilt is part of behavioral modification, not milieu therapy. Uncovering unconscious conflicts and fantasies is part of psychoanalytical, not milieu, therapy.

A nurse manager of a mental health unit has delegated medication administration to the licensed practical nurse (LPN). While supervising the LPN's technique, the nurse manager sees the LPN beginning to dispense an incorrect dose. How should the nurse manager respond initially? 1 By telling the LPN that an error has been made 2 By informing the nursing supervisor that the LPN is unsafe 3 By pointing out the error just before the LPN begins to administer the medication 4 By questioning the dosage in the hope that the LPN will identify the error

4Because the nurse is supervising, not evaluating, the LPN, questioning the dosage rather than pointing out the error is a positive approach that will allow the LPN to grow and help foster a supportive working relationship. Telling the LPN that an error has been made is not the initial intervention; this may become necessary if the LPN does not identify the error on his own. Informing the nursing supervisor is inappropriate and premature. Waiting until just before administration of the incorrect dose puts the client at risk.

A client has recently started taking a new neuroleptic drug, and the nurse notes extrapyramidal effects. Which drug does the nurse anticipate will be prescribed to limit these side effects? 1 Zolpidem (Ambien) 2 Hydroxyzine (Vistaril) 3 Dantrolene (Dantrium) 4 Benztropine mesylate (Cogentin)

4Benztropine (Cogentin), an anticholinergic, helps balance neurotransmitter activity in the central nervous system (CNS) and helps control extrapyramidal tract symptoms. Zolpidem (Ambien) is a sedative-hypnotic drug used for short-term insomnia. Hydroxyzine (Vistaril) is a sedative that depresses activity in the subcortical areas in the CNS; it is used to reduce anxiety. Dantrolene (Dantrium), a muscle relaxant, has a direct effect on skeletal muscle by acting on the excitation-contraction coupling of muscle fibers and not at the level of the CNS as do most other muscle relaxation drugs.

A client with schizophrenia is started on a regimen of chlorpromazine (Thorazine). After 10 days a shuffling gait, tremors, and some rigidity are apparent. Benztropine mesylate (Cogentin) 2 mg by mouth daily is prescribed. What should the nurse remember when administering these medications together? 1 Both medications are cholinesterase inhibitors. 2 The antipsychotic effects of chlorpromazine will be decreased. 3 The synergistic effect of these medications will cause drooling. 4 Both medications have a cholinergic blocking action.

4Both medications block central acetylcholine receptors. Neither medication inhibits cholinesterase; neostigmine (Prostigmin) acts in this manner. Although benztropine mesylate (Cogentin) can cause mental confusion when given in large doses, it does not reduce the antipsychotic effect of chlorpromazine (Thorazine). Both medications cause dry mouth.

A nurse in the mental health clinic is counseling a client with the diagnosis of depression. During the counseling session the client says, "Things always seem the same. They never change." The nurse suspects that the client is feeling hopeless. For what indication of hopelessness should the nurse assess the client? 1 Focused concentration 2 Preoccupation with delusions 3 Intense interpersonal relationships 4 Outbursts of anger

4Clients who are depressed and feeling hopeless also tend to have inappropriate expressions of anger. Depressed clients frequently have a diminished ability to think or concentrate. Preoccupation with delusions is usually associated with clients who have schizophrenia rather than with clients experiencing depression and hopelessness. Clients who are depressed and feeling hopeless tend to be socially withdrawn and do not have the physical or emotional energy for intense interpersonal relationships.

A nurse is counseling a client who is experiencing substance abuse delirium. What communication strategies should be used by the nurse when working with this client? 1 Encouraging the client to practice self-control 2 Using humor when communicating with the client 3 Approaching the client from the side rather than the front 4 Offering an introduction to the client at each meeting

4Clients with delirium have short-term memory loss; therefore it is necessary to reinforce information. A client experiencing delirium is unable to participate in a discussion about self-control. Humor is inappropriate and may cause the client to feel uncomfortable. Approaching the client from the side rather than the front may initiate a startle response, causing the client to become fearful.

A mental health nurse is working on a unit where many clients have the diagnosis of alcoholism. The nurse identifies that the defense mechanism most commonly used by clients who are alcoholics is: 1 Projection 2 Displacement 3 Compensation 4 Denial

4Denial is a method of resolving conflict or escaping unpleasant realities by ignoring their existence. The person denies that the drinking is out of control and causing problems. In projection the person faults another person for having unacceptable impulses, thoughts, or behaviors that are too uncomfortable to accept as one's own. In displacement the person transfers an emotion from one object, person, or situation to another (usually safer) object, person, or situation. In compensation the person makes up for personal inadequacies by emphasizing attributes to gain social approval.

A client recently admitted to the psychiatric unit is found to be experiencing command auditory hallucinations. The nurse conducts an initial one-on-one session centered on the development of trust. What is the next important nursing intervention? 1 Determining whether the command hallucinations are frightening to the client 2 Helping the client determine whether the voices are outside or inside the client's head 3 Determining the client's ability to refrain from listening to the messages from the voices 4 Identifying the content of the messages in the auditory hallucinations

4During the acute phase it is important to have the client describe the content of hallucinations so safety issues may be identified. Determining whether the command hallucinations are frightening to the client is not the priority; most clients find hallucinations frightening. Helping the client recognize whether the voices are outside or inside the client's head is not the priority. Determining the client's ability to refrain from listening to the messages from the voices is important, but it is not the priority at this time.

A client arrives at the clinic and tells the nurse about various aches and pains since her spouse's death 3 months ago. The client appears depressed and tense. What is the initial nursing intervention? 1 Focusing on teaching the client relaxation exercises 2 Asking the practitioner for a psychiatric consultation 3 Helping the client recognize ambivalence toward the spouse 4 Facilitating a discussion of the spouse's death

4Facilitating a discussion of the spouse's death will encourage the client to speak about the spouse and begin moving toward resolving the loss. Although relaxation exercises may be beneficial, the focus should be on the expression of feelings. A psychiatric consultation is not indicated by the data at this time. The data do not indicate ambivalence toward the spouse.

A client with the diagnosis of panic disorder jumps when spoken to, complains of feeling uneasy, and says, "It's as though something bad is going to happen." It is most therapeutic at this time for the nurse to: 1 Help the client to understand the cause of the feelings described. 2 Encourage the client to communicate with the staff. 3 Allow the client to set the parameters for the interaction. 4 Stay with the client to be a calming presence.

4Fear can be overwhelming; the nurse's presence provides protection from possible danger. The client's anxiety level is interfering with her ability to communicate; anxiety must be reduced first. The client's anxiety level is so high that sufficient emotional energy to set parameters is not available. Helping the client understand the cause of the feelings she describes may increase the client's anxiety at this time.

A client with mental health problems is given a prescription for fluphenazine (Prolixin). The nurse develops a teaching plan about the medication. What should the nurse caution the client to avoid? 1 Eating cheeses 2 Nighttime driving 3 Taking drugs containing aspirin 4 Staying in the sun

4Fluphenazine causes photosensitivity; severe sunburn may occur with exposure to the sun. There are no known side effects of fluphenazine (Prolixin) that affect the ability to drive at night. The client should avoid eating cheese if she is taking a monoamine oxidase inhibitor, not fluphenazine, which is a phenothiazine. Aspirin is not contraindicated for clients taking fluphenazine.

While assessing an older adult in the emergency department the nurse notes that the client is upset. The nurse asks what is wrong, and the client describes the current situation and then offers information that goes further and further off the topic. What pattern of communication does this conversation reflect? 1 Perseveration 2 Thought blocking 3 Overcompensation 4 Tangential thinking

4In tangential thinking the person never answers the question or returns to the central point of the conversation. It often is seen in people with dementia. Perseveration is the repetitive expression of a single idea in response to different questions; it is found most often in clients with cognitive impairments and those experiencing catatonia. Thought blocking is a sudden stoppage of the spontaneous flow of speaking for no apparent external reason; it is seen most often in clients who are experiencing auditory hallucinations. Overcompensation, also known as reaction formation, is a defense mechanism, not a pattern of communication.

A nurse working on a substance abuse unit knows that opioids most commonly are used because the individual: 1 Desires independence 2 Wants to fit in with the peer group 3 Enjoys the social interrelationships that occur 4 Is trying to reduce stress

4Individuals often take drugs because they cannot deal with the pain of reality; the drug blurs the pain and reduces anxiety. Drugs increase dependency rather than foster independence. Although the individual wanting to fit in with the peer encourages initial use by some adolescents, it is not the most common reason for their use. The use of drugs fosters social isolation. 1

A client who retired a year ago tells the nurse in the community health center, "I don't have any hobbies or interests, and since I retired I feel useless and unneeded." According to Erikson's developmental theory, with which developmental conflict is the client faced? 1 Initiative versus guilt 2 Intimacy versus isolation 3 Identity versus role confusion 4 Integrity versus despair

4Integrity versus despair is the task of the older adult; this client has not adapted to triumphs and disappointments, so there is no acceptance of what life is and was; this results in feelings of despair and disgust. Initiative versus guilt is the task of the preschool period. Intimacy versus isolation is the task of the young adult. Identity versus role confusion is the task of the adolescent.

A client becomes angry and threatens another client. What is the nurse's most therapeutic intervention? 1 Reminding the client that aggressive behavior is not tolerated on the unit 2 Revoking the client's telephone privileges for threatening another client 3 Assigning a staff member to monitor both clients when they are together 4 Encouraging the client to talk about why he or she became angry and then aggressive

4It is the nurse's responsibility to intervene and provide the client with support and a safe environment in which to problem solve a solution for his or her aggressive behavior. Encouraging a conversation about the triggers for the aggressive behavior is the most therapeutic of the options available. Reminding the client that aggressive behavior is not tolerated, revoking the client's telephone privileges, or assigning a staff member to monitor both clients when they are together are not incorrect options but lack the therapeutic impact of the correct option.

The nurse anticipates that the medication that will be used to prevent symptoms of withdrawal in clients with a long history of alcohol abuse is: 1 Phenobarbital (Luminal) 2 Chlorpromazine (Thorazine) 3 Methadone hydrochloride (Methadone) 4 Lorazepam (Ativan)

4Lorazepam (Ativan) is most effective in preventing the signs and symptoms associated with withdrawal from alcohol. It depresses the central nervous system by potentiating γ-aminobutyric acid, an inhibitory neurotransmitter. Phenobarbital (Luminal) is used to prevent withdrawal symptoms associated with barbiturate use. Chlorpromazine (Thorazine), an antipsychotic medication, is not used for alcohol withdrawal. Methadone hydrochloride (Methadone) is used to prevent withdrawal symptoms associated with opioid use.

A nurse is caring for a terminally ill client who is considering signing an "allow natural death" (AND) document rather than the traditional do-not-resuscitate (DNR) order. In light of the process of grieving, what feeling associated with end-of-life decisions is the AND advance directive attempting to alleviate? 1 Anger 2 Denial 3 Sadness 4 Guilt

4Many bereaved people blame themselves for not following the correct course of action in preventing the death. By framing the death as part of a natural process rather than the removal of an intervention, the nurse lessens the client's guilt. Anger may occur no matter what course of action is taken. Denial of death is less likely to occur when a DNR or AND is signed. Sadness may occur no matter what course of action is taken.

A nurse is caring for a client who is addicted to opioids and who has undergone major surgery. The client is receiving methadone. What is the purpose of this medication? 1 Allows symptom-free termination of opioid addiction 2 Provides postoperative pain control without causing opioid dependence 3 Counteracts the depressive effects of long-term opioid use on thoracic muscles 4 Switches the user from illicit opioid use to use of a legal drug

4Methadone may legally be dispensed; the strength of this drug is controlled and remains constant from dose to dose, unlike illicit drugs. Methadone is used in the medically supervised withdrawal period to treat physical dependence on opiates; methadone therapy substitutes a legal for an illegal drug. Methadone may be administered over the long term to replace illegal opioid use. If methadone treatment is abruptly stopped, there will be withdrawal symptoms. Methadone is a synthetic opioid and can cause dependence; it is used in the treatment of heroin addiction but may be prescribed for people who have chronic pain syndromes. It is not used for acute postoperative pain. Methadone is not known to counteract the depressive effects of long-term opioid use on thoracic muscles.

A 42-year-old adult with a long history of alcohol abuse seeks help in one of the local hospitals. The nurse considers that the major underlying factor for success in an alcohol treatment program is the client's: 1 Family 2 Practitioner 3 Self-esteem 4 Motivation

4Motivation is necessary to help the client withstand the pain of giving up a defense; internal motivation is more influential in facilitating change than any external factor. Although having family support is important, internal motivation to change is the most important factor. The client's practitioner can be of assistance, but internal factors will have a greater effect on rehabilitation than external factors. Self-esteem will be useful if it precipitates abstinence behavior; however, people who are alcoholics commonly have low self-esteem.

A nurse is working with a married woman who has come to the emergency department several times with injuries that appear to be related to domestic violence. While talking with the nurse manager, the nurse expresses disgust that the woman keeps returns to the situation. What is the best response by the nurse manager? 1 "She must not have the financial resources to leave her husband." 2 "There's nothing the staff can do; people are free to choose their own lives." 3 "These women should be told how stupid they are to stay in that kind of situation." 4 "Most women try to leave about six times before they are successful."

4Nurses who work with victims of partner abuse need to be supportive and patient. It takes time and several attempts for most victims to leave abusive relationships. It may or may not be true that the client doesn't have the financial resources to leave her husband; there is not enough information to support this conclusion. The staff can encourage the woman to make plans for addressing various potential events and provide information about social services and telephone help lines. Shaming women in this position will simply make them less likely to seek help.

A client newly admitted to the psychiatric unit because of an acute psychotic episode is actively hallucinating. The admitting nurse has documented the content of the auditory hallucinations, which center on the theme of powerlessness. Later the primary nurse approaches the client, who appears to be listening to voices, and comments, "You seem to be listening to something. Tell me what you hear." The primary nurse requests feedback from the psychiatric clinical specialist regarding this nursing intervention. How should the clinical specialist respond? 1 By suggesting that the nurse use an open-ended approach and asking the nurse to discuss the correlation between positive behaviors observed and prescribed antipsychotics 2 By giving positive feedback for the nurse's attempt to explore the content of the client's hallucinations and reinforcing the need to continue this approach 3 By recognizing this as a positive intervention and helping the nurse develop a plan of care that calls for a contract to refrain from acting on command hallucinations 4 By reminding the nurse that once the content is known, there is no need to focus on the hallucinations because doing so reinforces them

4Once the content of the hallucination is known and it is not a command to harm the self or others, focusing on the hallucinations is not therapeutic; recognizing feelings, pointing out reality, and learning to use strategies to push aside hallucinations are therapeutic. Giving positive feedback reinforces the nurse's inappropriate approach with the client; continuing this approach reinforces the value of the hallucinations for the client, which is undesirable. This is a negative, not a positive, intervention; also, no data support the fact that the client is experiencing command hallucinations. Clear, concise, direct communication is more desirable when clients are experiencing hallucinations, which are usually frightening; although positive behaviors are a response to antipsychotic medications, these should not be the primary focus of this supervisory session.

An older adult is brought to the clinic by a family member because of increasing confusion over the past week. What can the nurse ask the client to do to assess orientation to place? 1 Explain a proverb. 2 Give the state where she was born. 3 Recall what she ate for breakfast. 4 Identify the name of the clinic's town.

4Orientation to place refers to an individual's awareness of the objective world in its relation to the self; orientation to time, place, and person is part of the assessment of cerebral functioning. Explaining a proverb requires abstract thinking, which involves a higher integrative function than does orientation to place. Having the client state where she was born helps the nurse assess remote memory, not orientation. Having the client recalling what she had for breakfast helps assess recent memory, not orientation.

A woman who is frequently physically abused tells the nurse in the emergency department that it is her fault that her husband beats her. What is the most therapeutic response by the nurse? 1 "Maybe it was your husband's fault, too." 2 "I can't agree with that—no one should be beaten." 3 "Tell me why you believe that you deserve to be beaten." 4 "You say that it was your fault—help me understand that."

4Paraphrasing and clarifying are interviewing techniques that promote communication between the nurse and client and help the client hear and explore her words and gain insight into her behavior. Asking a "why" question is generally not therapeutic because most clients cannot respond to these questions with logical explanations. "Maybe it was your husband's fault, too" is a declarative statement that is closed, will limit dialog, and is not therapeutic.

A nurse in a long-term care facility is caring for a bedridden client with multiple chronic illnesses. Although usually continent, the client expresses anger through urinary incontinence. What should the nurse do to best address this situation? 1 Offer the client a bedpan every 2 hours. 2 Encourage the client to watch more television. 3 Decrease the client's fluid intake in the evening. 4 Assist the client in setting realistic short-term goals.

4People with chronic illnesses often feel helpless and powerless. This can turn into anger and acting-out behaviors against those providing care. Helping the client set and achieve realistic short-term goals fosters client independence and hope. Because the client is able to control elimination, frequent toileting is not the problem. Although distraction is important, it should be varied and the client's preferences taken into consideration. Radio and television do not promote interaction. As a means of preventing urinary stasis and dehydration, fluid intake should be encouraged. Also, restricting fluid intake will not prevent intentional incontinence.

A single mother of two children who recently lost her job because her company is downsizing comes to the emergency department. The woman does not know what to do and is in crisis. The most critical factor for the nurse to determine during crisis intervention is the client's: 1 Developmental history 2 Underlying unconscious conflict 3 Willingness to restructure the personality 4 Available situational supports

4Personal internal strengths and supportive individuals are critical to the development of a crisis intervention plan; they must be explored with the client. Although developmental history information may be helpful, it is not essential; factors concerning the current situation are paramount. Identifying unconscious conflicts takes a long time and is inappropriate for crisis intervention. Willingness to restructure the personality is a goal of psychotherapy, not crisis intervention.

A client arrives at the mental health clinic complaining about feelings of extreme terror when attempting to ride in an elevator and feelings of uneasiness in large crowds. He reports that these fears are interfering with his concentration at work. What does the nurse identify as the source of these symptoms? 1 Conflict with society, resulting in an obsession 2 Depression about life events, resulting in unreasonable fears 3 Repression of a terrifying incident in an elevator, resulting in an obsession 4 Generalized anxiety about conflicts, resulting in unreasonable fears

4Phobias are specific fears that often serve as a means of coping with generalized anxiety. Conflicts with society do not result in phobias. Although depression is related to phobias, finding a direct connection to life events is difficult.

The nurse understands that paranoid delusions may be related to the defense mechanism of: 1 Regression 2 Repression 3 Identification 4 Projection

4Projection is a mechanism in which inner thoughts and feelings are projected onto the environment, seeming to come from outside the self rather than from within. Regression is the use of a behavioral characteristic appropriate to an earlier level of development. Repression is the involuntary exclusion of painful or conflicting thoughts from awareness. Identification is taking on the thoughts and mannerisms of an individual who is admired or idealized.

What should be a priority of nursing care for a client with a dementia resulting from AIDS? 1 Frequent assessments for pain 2 Planning for remotivational therapy 3 Arranging for long-term custodial care 4 Providing basic intellectual stimulation

4Providing basic intellectual stimulation maintains, for as long as possible, the client's remaining intellectual functions by providing an opportunity to use them. Although pain syndromes can occur in clients with dementia resulting from AIDS, frequent pain assessment is not a priority; providing cognitive stimulation facilitates the use of nonpharmacological treatments for pain management as long as possible. Remotivation is not always possible with extensive organic brain damage. There are no data to indicate that the client needs custodial care at this time.

A client has been receiving oxycodone (OxyContin) for moderate pain associated with multiple injuries sustained in a motor vehicle collision. The client has returned three times for refills of the prescription. What behavior, in addition to the client's slurred speech, leads the nurse to suspect opioid intoxication? 1 Mood lability 2 Hypervigilance 3 Increased respirations 4 Constricted pupils

4Pupil constriction is a physical response to opioid intoxication; the pupils will dilate with opioid overdose. Opioids cause apathy or a depressed, sad mood (dysphoria); lability of mood is associated with the use of anabolic-androgenic steroids. Opioids cause drowsiness and psychomotor retardation; alertness is associated with the use of stimulants such as caffeine and amphetamines. Opioids depress the respiratory center of the brain, causing slow, shallow respirations; increases in temperature, pulse, respirations, and blood pressure are associated with cocaine use.

A nurse on a mental health unit has developed a therapeutic relationship with a manipulative, acting-out client. One day as the nurse is leaving, the client says, "Please stay. I'm afraid that the evening staff doesn't like me. They're always punishing me." What is the nurse's most therapeutic response? 1 "I'll ask the staff not to punish you." 2 "Tell me more about what you're feeling now." 3 "Don't worry. I told you, everything will be all right." 4 "You know I leave at this time. We'll talk about this in the morning."

4Reminding the client that the nurse leaves at this time each day and telling him that they will discuss the issue in the morning demonstrates acceptance of the client and sets limits on the client's manipulative behavior. "I'll ask the staff not to punish you" reinforces the client's belief that the evening staff is punishing him and could result in a split among the staff members. Asking the client to reveal more about what he is feeling now indicates that the nurse has been manipulated by the client. Telling the client not to worry and that everything will be all right is false reassurance; the nurse cannot make everything all right.

What is the primary reason that the nurse encourages the family of an alcoholic to become involved in the treatment program? 1 Alcoholics try to hide their drinking from their families. 2 Family members provide insights into the dynamics behind the drinking. 3 Family members have been most successful in providing necessary support. 4 Alcoholism involves the entire family

4Research indicates that alcoholism is a family disease, with its roots in the family of origin. Although alcoholics may try to hide their drinking from their families, this is not the reason for including the family in the treatment program. Family members often have no understanding of the dynamics behind the drinking and often need assistance with coping and counseling. Family members often do not understand the dynamics behind the drinking and often are enablers; they also need assistance with coping and counseling.

As the nurse is discussing psychiatric care with an older adult client, the client says, "When I was growing up I was taught to accept my lot in life and not complain. I'm proud of the fact that despite my issues I can still function independently. I don't want to be just put away." The nurse understands that the factors that influence the client's mental health are examples of: 1 Setting of care 2 Anxiety disorder 3 Cultural and ethnic disparities 4 Attitudes and beliefs

4Some attitudes and beliefs include reluctance by older people to seek help because of pride in their independence, stoic acceptance of difficulty, unawareness of resources, and fear of being "put away." Although the client mentions "being put away", that is an attitude. He is not talking about all the resources that might be available to him. Anxiety is defined as an unpleasant and unwarranted feeling of apprehension. The client does not mention any cultural or ethnic issues, just his own feelings.

What is the primary concern for a nurse caring for a client who is grossly impaired by stimulants? 1 Drowsiness 2 Fluid imbalance 3 Suicidal ideation 4 Seizure activity

4Stimulants increase the excitatory neurotransmitters (e.g., adrenaline and dopamine), lowering the seizure threshold. A person who is under the heavy influence of stimulants will be unable to rest and sleep because of stimulation of the sympathetic nervous system. Although dehydration may occur, it is not the priority concern. Suicidality is of greatest concern during stimulant withdrawal, not when a client is grossly impaired by stimulants.

Channeling energy to healthy physical activities can decrease violent behavior. A behavioral contract is used to reinforce problem solving and encourage the use of social skills. Successful experiences improve the client's self-esteem and should decrease the manipulative behavior. Clients with conduct disorders tend to generate stress for others, not the other way around. Verbalization of negative feelings to others can often escalate and result in antisocial or acting out behavior.

4Stimulating the central nervous system with cocaine most commonly causes these responses, which can progress to fear, hallucinations, paranoid delusions, and violent behavior. Nausea is not a side effect. Euphoria, rather than fatigue, and loss of appetite, rather than hunger, are side effects. Seizures, hoarseness, and electrolyte imbalance are not common side effects of cocaine use. An increase in energy, rather than lethargy, occurs. Some cocaine users believe that the drug maximizes sexual experiences, but there is no documentation of this physiological response. Hormone imbalances are not common side effects.

During a nursing team conference, a mental health worker suggests that a client with schizophrenia, paranoid type, be assigned to group therapy. What should the nurse manager explain about this type of therapy for this client? 1 Individuals with this disorder respond well to small therapeutic groups. 2 Compliance with unit rules and medication regimens increases as therapeutic group involvement increases. 3 Involvement in small therapeutic groups may decrease the regression and dependency associated with institutionalization. 4 Therapeutic group work tends to be threatening to individuals who are suspicious.

4Suspicious individuals do not do well in groups because they are unable to tolerate the give-and-take that is necessary for successful group function. Suspicious individuals do not trust others enough to do well in group therapy. The assertion that compliance with unit rules and medication regimens increases as therapeutic group involvement increases may not be true for acutely ill psychiatric clients, who are not ready to accept reality. Reducing problems related to institutionalization is not the purpose of group therapy. These problems are addressed with remotivation therapy.

After caring for a terminally ill client for several weeks, a nurse becomes increasingly aware of a need for a respite from this assignment. What is the best initial action by the nurse? 1 Requesting a few days' vacation time 2 Withdrawing emotional involvement with the client 3 Staying with the client while trying to work through the feelings 4 Seeking support from colleagues on the unit

4Talking with colleagues who face or who have faced the same problems may provide constructive help with the situation. Requesting vacation time is an avoidance technique; these feelings must be addressed. Withdrawing emotional involvement with the client does not address the needs of the nurse and may interfere with a productive nurse-client relationship. Staying with the client while trying to work through the feelings does not address the needs of the nurse and may interfere with a productive nurse-client relationship.

A woman who has severe rheumatoid arthritis becomes depressed and is admitted to the psychiatric unit. The nurse begins to work with her in one-on-one sessions to help her cope with her depressive episode. The best long-term goal for this client is that she will: 1 Eat at least two meals per day with other clients. 2 Maintain self-care and attend structured activities. 3 Make a positive verbal comment to another client daily. 4 Decrease negative thinking about herself, others, and life.

4The best long-term goal is that the client attains a positive attitude about the self, others, and life in general; this indicates that treatment has been effective and the client may be discharged. Eating at least two meals per day with other clients is a short-term goal associated with a therapeutic milieu. Maintaining self-care and attending structured activities is a short-term goal and an expected behavior on an inpatient unit. Making a positive verbal comment to another client daily is an intermediate goal that helps the client focus on others; this goal is a step toward achieving long-term goals.

A client who has recently been found to be infected with HIV comments to the nurse, "There are so many terrible people around. Why couldn't one of them get HIV instead of me?" What is the best response by the nurse? 1 "It might be good for you to speak with your religious leader." 2 "I'm sure you really don't wish this on someone else." 3 "I'm sure you know that HIV infection is now considered a chronic illness." 4 "It seems unfair that you should have this disease."

4The client is in the anger or "why me" stage of grieving; encouraging the client to express feelings will help the client resolve them while moving toward acceptance. "I'm sure you really don't wish this on someone else" is a judgmental response that may create a rift in the nurse-client relationship. Suggesting that the client speak with a religious leader may precipitate guilt feelings and ignores the current concern. "I'm sure you know that HIV infection is now considered a chronic illness" does not reflect what the client said; people with newly diagnosed chronic illnesses grieve for their loss of health.

A person who is hospitalized for alcoholism becomes boisterous and belligerent and verbally threatens the nurse. What is the most appropriate response by the nurse? 1 Placing the client in restraints 2 Encouraging the client to play some table tennis with another client 3 Setting firm limits on the client's behavior and enforcing adherence to them 4 Sedating the client and placing her in a controlled environment

4The client is out of control and therefore dangerous to herself and others. Safety requires sedation and a controlled environment. Restraining a disturbed, belligerent client can result in injury because restraints generally increase anxiety and acting out. The client's attention span is too short for table tennis. Any measures directed at verbal or physical correction of the client's behavior will be taken to no avail.

A client with dementia has been cared for by the spouse for 5 years. During the last month the client has become agitated and aggressive and is incontinent of urine and feces. What is the priority nursing care while this client is in an inpatient mental health facility? 1 Preventing further deterioration 2 Focusing on the needs of the spouse 3 Establishing an elimination retraining program 4 Managing the behavior

4The client must be kept from harming self or others and needs a calm, supportive environment that meets needs and maintains dignity. Alzheimer dementia is characterized by progressive deterioration that is not preventable; however, some drugs, such as donepezil (Aricept) may slow mild to moderate dementia. Although addressing the needs of family members is important, the focus of care is primarily on the client. Establishing an elimination retraining program may be unrealistic and is not the priority.

A disturbed male client, unprovoked, attacks another client. A short-term initial plan for this client should include: 1 Placing the client in restraints or secluding the client 2 Keeping the client actively participating in activities and in contact with reality 3 Getting the client to apologize for the attack to the other client and to show remorse 4 Having the client sit with a staff member in whom he trusts

4The client needs someone with whom he has a working and trusting relationship; this individual must observe, protect, anticipate, and prevent the client from acting out destructive impulses. Restraints or seclusion may eventually be necessary, but they are too restrictive for an initial intervention. Although there is a need to keep clients in touch with reality, this client may not be ready for participation. At this time the client cannot be held responsible for his aggressive behavior.

A major recognizable difference between anorexia nervosa and bulimia nervosa is that clients with anorexia nervosa usually: 1 Tend to be more extroverted than clients with bulimia 2 Seek intimate relationships, whereas clients with bulimia avoid them 3 Are at greater risk for fluid and electrolyte imbalances than are clients with bulimia 4 Deny the problem, whereas clients with bulimia generally recognize that their eating pattern is abnormal

4The client with anorexia nervosa denies the need for food or presence of hunger; the client with bulimia nervosa hides the behavior because she recognizes that the behavior is a problem. Clients with bulimia are at a greater risk for fluid and electrolyte problems because of the purging; clients with anorexia nervosa are at greater risk for severe nutritional deficiencies. Clients with anorexia nervosa are more introverted and tend to avoid relationships.

A male client with cyclothymic disorder with hypomanic symptoms is admitted to the psychiatric unit. He has progressively lost weight and does not take the time to eat his food. How can the nurse best respond to this situation? 1 By providing a tray for him in his room 2 By assuring him that he is deserving of food 3 By pointing out that he must replace the energy that he is burning up by eating 4 By ordering food that he can hold in his hand to eat while moving around

4The client with hypomanic symptoms cannot tolerate sitting still long enough to eat an adequate meal; handheld foods will help meet the client's nutritional needs and do not require the client to sit down. This client will most likely ignore the tray. Unworthy feelings are related to a depressive, not manic, episode. It is unlikely that this client will understand or care about the need to replace energy with food.

Fourteen months after the traumatic death of a spouse, a client comes to the mental health clinic complaining of continuing depression and states, "I haven't been seeing any of my friends or attending any of the activities I previously enjoyed. My children are married and live in another state, and I almost never see them." What does the nurse determine that the client is experiencing? 1 Ineffective family interactions 2 Problems in communicating with others 3 Low motivation to resume daily activities 4 Difficulty grieving

4The client's grieving process is severe and extended, indicating dysfunction. There are not enough data to support the conclusion that the family's interactions are ineffective. The data do not indicate problems with communication; the client is communicating effectively with the nurse. Low motivation is not the reason for the client's inability to cope.

At 4 am on a Saturday a client calls the crisis hotline. On what should the nurse focus during the initial assessment? 1 Family constellation 2 Inability to control the situation 3 Previous methods used for crisis resolution 4 Perception of the crisis event

4The client's perception of the event is essential to determining what the situation means to the client and what action can be taken. Family constellation will be important later; however, the current crisis is the immediate focus. The nurse should focus on helping the client gain control of the situation within a workable frame of reference. The focus should be positive and relate to what the client can do, not what the client is unable to do. If previous methods of coping were effective, the client would not be in a crisis. The focus should be on the immediate situation; previous crisis resolution methods may be addressed later.

A client visits the mental health clinic because of an aversion to arachnids. The client reports screaming hysterically when a spider is in the vicinity and indicates that this phobia is interfering with her job performance. What defense mechanisms does the nurse conclude that the client is using? 1 Undoing and sublimation 2 Repression and identification 3 Introjection and reaction formation 4 Displacement and projection

4The defense mechanisms of displacement and projection defense are related to phobias; displacement is the release of pent-up feelings onto something or someone else that is less threatening than the original source of the feelings, and projection is the attribution of one's own unacceptable characteristics or motives to another. Undoing and sublimation are not related to phobias; undoing is an attempt to atone for unacceptable acts or wishes; sublimation is the channeling of unacceptable impulses into constructive acceptable behaviors. Repression is the unconscious process of keeping from the consciousness ideas or impulses that are unacceptable to the individual; suppression is the conscious inhibition of an idea, impulse, or affect. Neither is related to phobias. Introjection is treating something outside the self as if it is actually inside the self; reaction formation is the expression of unacceptable desires by the use of opposite behaviors in an exaggerated way. Neither is related to phobias.

A nurse is caring for a client who has been hospitalized for alcohol withdrawal. The client decides to attend an Alcoholics Anonymous meeting. What is a basic principle of this group? 1 Spouses should attend Al-Anon meetings. 2 A commitment to permanent abstinence must be made. 3 People have the power to overcome alcoholism if they truly want to stop drinking. 4 Amends must be made to each person who has been harmed.

4The eighth step of the 12 steps of Alcoholics Anonymous (AA) is "Made a list of all persons we had harmed, and became willing to make amends to them all." Attendance of Al-Anon meetings by the spouses of alcoholics is not a basic principle of AA; attendance is the decision of the individual exposed to the alcoholic. AA focuses on one day at a time. The program holds that alcoholics are powerless to overcome alcoholism and that their lives have become unmanageable; recovering alcoholics believe that a power greater than themselves will help them recover.

A depressed client often sleeps past the expected time of awakening and spends excessive time resting and sleeping. Which nursing intervention is appropriate for this client? 1 Offering the client a series of relaxation tapes 2 Rescheduling the client's bedtime to an earlier hour 3 Suggesting that the client exercise before going to bed 4 Restricting the client's access to the bedroom

4The goal is 6 to 8 hours of rest at night; too much time spent sleeping in the daytime will defeat the goal of adequate rest at night. Offering the client a series of relaxation tapes will contribute to the client's desire for relaxation and sleep. Rescheduling the client's bedtime to an earlier hour will support the client's hypersomnia; the client already sleeps too much. Suggesting that the client exercise before going to bed will increase the metabolic rate, which is not conducive to rest.

Although upset by a young client's continual complaints about all aspects of care, the nurse ignores them and attempts to divert the conversation. Immediately after this exchange with the client, the nurse discusses with a friend the various stages of development of young adults. Which defense mechanism is the nurse is using? 1 Sublimation 2 Substitution 3 Identification 4 Intellectualization

4The nurse is using facts and knowledge to detach herself from the emotional impact of the client's problem and to ease the anxiety it is causing. Sublimation is the channeling of unacceptable thoughts or feelings into acceptable activity. Substitution is similar to displacement; anxiety is reduced with a transfer of the emotions associated with an object or person to another, safer object or person. Identification is trying to unconsciously imitate the behavior of another who is considered important in an attempt to incorporate the important aspects of this individual into the self.

While a client is attending an Alcoholics Anonymous (AA) meeting, a nurse talks with the client's spouse about the purpose of AA. What is the priority goal of this self-help group? 1 Developing functional relationships 2 Identifying how people present themselves to others 3 Understanding patterns of interacting within the group 4 Changing destructive behavior

4The purpose of a self-help group is for individuals to develop their strengths and new, constructive patterns of coping. Developing functional relationships, identifying how people present themselves to others, and understanding patterns of interaction within the group are purposes of group therapy.

While walking down the hall a female client with schizophrenia stops and stands rigidly. When asked what she is doing, she replies slowly, "I'm standing here because Jesus told me to." What is the best response by the nurse? 1 "Come to your room for a while; you'll feel better." 2 "What you heard was in your head; it was your imagination." 3 "Jesus wouldn't tell you to stand in the hall; he wants you to behave reasonably." 4 "I didn't hear anyone talking; come with me to the community room."

4The response "I didn't hear anyone talking; come with me to the community room." points out reality without focusing on the hallucination and provides a reality-based diversion. Although the response "Come to your room for a while; you'll feel better" might be a reality-based diversion, it provides false reassurance because the client may or may not feel better. The response "What you heard was in your head; it was your imagination" minimizes what the client is experiencing and may be perceived as demeaning. The response "Jesus wouldn't tell you to stand in the hall; he wants you to behave reasonably" is accusatory and demeaning; it implies that the client is unreasonable at a time when the client needs to be accepted and supported.

A client with a diagnosis of schizophrenia, undifferentiated type, was admitted to the mental health hospital 3 days ago. The client stays in the bedroom except to eat and has no verbal interaction with other clients. When the nurse approaches, the client walks away and says, "Just leave me alone." What is the best response by the nurse? 1 "We need to talk." 2 "What are you angry about?" 3 "Is there a reason to be so upset?" 4 "I'll talk to you later."

4The response "I'll talk to you later" allows the client to have the choice of communicating and leaves channels of communication open. The response "We need to talk" does not provide for any choice by the client. The response "What are you angry about?" assumes that the nurse knows the client's feelings; the nurse should not make this assumption. "Is there a reason to be so upset?" is a judgmental response; the nurse should not make the assumption that the client is upset.

At a group therapy session a member, in a teasing manner, makes several negative remarks about the nurse's appearance and behavior. The nurse can best respond by saying to the: 1 Group, "What do you think that this client is trying to tell me?" 2 Group, "Do you think that this client's behavior is appropriate today?" 3 Client, "I can't just sit here letting you talk about me this way. What have I done to make you angry?" 4 Client, "You seem very interested in my appearance and behavior. What's this all about?"

4The response "You seem very interested in my appearance and behavior. What's this all about?" focuses the client on the behavior and on what the client is trying to achieve by such behavior; it also helps the client understand how such behavior affects others. The group will not know what the client was trying to tell the nurse; only the client knows. "Do you think this client's behavior is appropriate today?" uses a nondirect approach to attack the client. The response "I can't just sit here letting you talk about me this way. What have I done to make you angry?" is an attacking, defensive response that is made without knowing what the client is attempting to accomplish.

A female client undergoing presurgical testing before a possible colon resection and colostomy says to the nurse, "If I have to have this surgery, I know that my husband will never come near me again." What is the most therapeutic response by the nurse? 1 "You're probably underestimating his love for you." 2 "Are you worried that the surgery will change how others see you?" 3 "Are you wondering about the effect of surgery on your ability to function sexually?" 4 "You're concerned about how your husband will respond to your surgery."

4The response "You're concerned about how your husband will respond to your surgery" is an open-ended response that encourages further discussion without focusing on an area that the nurse, not client, feels is the problem. The response "You're probably underestimating his love for you" denies the client's feelings and may cause feelings of guilt for questioning the partner's love. Also, the nurse has no knowledge of the presence or lack of love they have for each other. The response "Are you worried that the surgery will change how others see you?" shifts the focus from the client's voiced concerns; the client specifically referred to her husband, not other people. The response "Are you wondering about the effect of surgery on your ability to function sexually?" is too specific; the nurse does not have enough information to come to this conclusion.

The nurse is planning care for a confused, delusional client. What should be included in the plan to render it as therapeutic as possible? 1 Minimizing stimuli by maintaining a quiet environment 2 Understanding that these adaptations make differentiating fantasy from reality difficult 3 Demonstrating that the client is worthy of receiving care by providing physical hygiene 4 Encouraging realistic activity based on the client's ability

4These clients need sensory stimulation to maintain orientation and should be encouraged to do as much as possible for themselves, depending on their ability. Surroundings should be bright to minimize confusion. Stimuli distract a delusional client. These clients usually are not completely out of contact with reality; it is important to differentiate fantasy from reality, but this is not the priority. Although it is important to ensure that clients receive physical hygiene and comfort, they should be encouraged to help themselves as much as possible.

A client with a history of alcoholism is found to have Wernicke encephalopathy associated with Korsakoff syndrome. What does the nurse anticipate will be prescribed? 1 Oral administration of chlorpromazine 2 Traditional phenothiazine 3 Judicious use of antipsychotics 4 Intramuscular injections of thiamin

4Thiamine is a coenzyme necessary for the production of energy from glucose. If thiamine is not present in adequate amounts, nerve activity is diminished and damage or degeneration of myelin sheaths occurs. A traditional phenothiazine is a neuroleptic antipsychotic that should not be prescribed because it is hepatotoxic. Antipsychotics are avoided; the use of these has a higher risk for toxic side effects in older or debilitated persons. Chlorpromazine, a neuroleptic, will not be used because it is severely toxic to the liver.

A client is brought by ambulance to the emergency department. The client's signs and symptoms are indicative of opioid overdose. What should the nurse expect the practitioner to prescribe? 1 Methadone 2 Epinephrine 3 Amphetamine 4 Naloxone

4This drug is an opioid antagonist that displaces opioids from receptors in the brain, reversing respiratory depression. Methadone is a synthetic opioid that causes central nervous system depression; it will accelerate the effects of the overdose. Epinephrine will have no effect on respiratory depression stemming from of an overdose of a narcotic. Amphetamine is a stimulant, not an opioid antagonist.

A female client is admitted to the hospital after attempting suicide. She reveals that her desire for sex has diminished since her child's birth 3 years ago. What is most directly related to the client's loss of interest in sex? 1 Dependency 2 Marital stress 3 Identity confusion 4 depression

4VDecreased sexual desire is a major symptom of clinical depression. Other vegetative signs of depression include changes in bowel elimination, eating habits, and sleeping patterns. Although depression is often related to unmet dependency needs, the decreased sexual desire is associated with the depression, not the unmet dependency needs. The sexual difficulties are associated with the depression, and the depression, not the sexual difficulties, may be the major cause of marital stress. Also, there are no data indicating marital stress. Role confusion, not identity confusion, is usually associated with depression.

A nurse is evaluating the medication regimens of clients to determine whether the therapeutic levels have been achieved. For which medication should the nurse review the client's serum blood level? 1 Olanzapine (Zyprexa) 2 Sertraline (Zoloft) 3 Lorazepam (Ativan) 4 Valproic acid (Depakene

4Valproic acid (Depakene) must reach a therapeutic level to be effective, and the serum level must be monitored to ensure that it remains in the therapeutic range rather than the toxic range. The serum drug level is not monitored with lorazepam (Ativan) or olanzapine (Zyprexa).

In the process of development the individual strives to maintain, protect, and enhance the integrity of the self. The nurse determines that this is usually accomplished through the use of: 1 Affective reactions 2 Withdrawal patterns 3 Ritualistic behaviors 4 Defense mechanisms

4When the individual experiences a threat to self-esteem, anxiety increases, and defense mechanisms are used to protect the self. Affective reactions are mood disorders. Withdrawal patterns are deviant ways of coping with stress; if carried to an extreme, behavior may become pathological. Ritualistic behaviors are not an aspect of the developmental process.

57. Over a period of several weeks, one male participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation? A) Talk to the client outside the group about his behavior during group meetings. B) Remind the client to allow others in the group a chance to talk. C) Allow the group to handle the problem. D) Ask the client to join another group.

After several weeks, the group is in the working phase and the group members should be allowed to determine the direction of the group. The nurse should ignore the client's comments and allow the group to handle the situation (C). A good leader should not have separate meetings with group members (A), as such behavior is manipulative on the part of the leader. (B) is dictatorial and is not in keeping with good leadership skills. (D) is avoiding the problem. Remember, identify what phase the group is in--initial, working, or termination--this will help determine communication style. Correct Answer(s): C

75. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of what condition? A) Claustrophobia. B) Acrophobia. C) Agoraphobia. D) Post-traumatic stress disorder.

Agoraphobia (C) is the fear of crowds or being in an open place. (A) is the fear of being in closed places. (B) is the fear of high places. Remember, a phobia is an unrealistic fear which is associated with severe anxiety. (D) consists of the development of anxiety symptoms following a life event that is particularly serious and stressful (war, witnessing a child killed, etc.) and is experienced with terror, fear, and helplessness--a phobia is different. Correct Answer(s): C

36. A 27-year-old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care? A) Schedule her to attend various group activities. B) Reinforce her ability to make her own decisions. C) Encourage her to identify feelings of anger. D) Provide a structured environment with little stimuli.

Clients in the manic phase of a bipolar disorder require decreased stimuli and a structured environment (D). Plan noncompetitive activities that can be carried out alone. (A) is contraindicated; stimuli should be reduced as much as possible. Impulsive decision-making is characteristic of clients with bipolar disorder. To prevent future complications, the nurse should monitor these clients' decisions and assist them in the decision-making process (B). (C) is more often associated with depression than with bipolar disorder. Correct Answer(s): D

24. On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which class of disorder? A) Neurotic. B) Personality. C) Anxiety. D) Psychotic.

Delusions are false beliefs associated with psychotic behavior, and psychotic persons are not in touch with reality (D). (A, B, and C) are mental health disorders which are not associated with a break in reality, nor with hallucinations (false sensations such as hearing, or seeing) or delusions (false beliefs). Correct Answer(s): D

5. A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take? A) Notify the healthcare provider immediately and prepare for administration of an antidote. B) Notify the healthcare provider of the symptoms prior to the next administration of the drug. C) Record the symptoms as normal side effects and continue administration of the prescribed dosage. D) Hold the medication and refuse to administer additional amounts of the drug.

Early side effects of lithium carbonate (occurring with serum lithium levels below 2.0 mEq per liter) generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness, and muscular weakness. At higher levels, ataxia, tinnitus, blurred vision, and large dilute urine output may occur. (B) is the best choice. Although these are expected symptoms, the healthcare provider should be notified prior to the next administration of the drug. (A, C, and D) would not reflect good nursing judgment. Correct Answer(s): B

70. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. The nurse knows that the client is using which defense mechanism? A) Sublimation. B) Identification. C) Introjection. D) Repression.

Identification (B) is an attempt to be like someone or emulate the personality traits of another. (A) is substituting an unacceptable feeling for one that is more socially acceptable. (C) is incorporating the values or qualities of an admired person or group into one's own ego structure. (D) is the involuntary exclusion of painful thoughts or memories from one's awareness. Correct Answer(s): B

64. Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior? A) Administer a prescribed PRN antianxiety medication. B) Assist the client to identify stimuli that precipitates the ritualistic activity. C) Allow time for the ritualistic behavior, then redirect the client to other activities. D) Teach the client relaxation and thought stopping techniques.

Initially, the nurse should allow time for the ritual (C) to prevent anxiety. (A) may help reduce the client's anxiety, but will not prevent ritualistic behavior resulting from the client's ineffective coping ability. (B) is a long-term goal of individual therapy, but is not directly related to controlling the behavior at this time. (D) lists techniques that can be used to assist the client in learning new ways of interrupting obsessive thoughts and resulting ritualistic behavior as treatment progresses. Correct Answer(s): C

50. A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? A) Perphenazine (Trilafon). B) Diphenhydramine (Benadryl). C) Chlordiazepoxide (Librium). D) Isocarboxazid (Marplan).

Librium (C), an antianxiety drug, as well as other benzodiazepines, are used in titrated doses to reduce the severity of abrupt benzodiazepine withdrawal. (A) is an antipsychotic agent. (B) is an antihistamine and antianxiety drug. (D) is an MAO inhibitor. Correct Answer(s): C

72. A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make? A) How can I help? B) Things probably aren't as bad as they seem right now. C) Let's talk about what is right with your life. D) I hear how miserable you are, but things will get better soon.

Offering self shows empathy and caring (A), and is the best of the choices provided. Combining the first part of (D) with (A) would be the best response, but this is not a fill-in-the-blank or an essay test! Choose the best of those choices provided and move on. (B) dismisses the client, things are bad as far as this client is concerned. (C) avoids the client's problems and promotes denial. "I hear how miserable you are" is an example of reflective dialogue and would be the best choice if it were not for the rest of the sentence--"but things will get better" which is offering false reassurance. Correct Answer(s): A

42. On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity? A) Clean the unit kitchen cabinets. B) Participate in a group quilting project. C) Watch television in the activity room. D) Bake a cake for a resident's birthday.

Peer interaction in a group activity (B) will help to prevent social isolation and withdrawal. (A, C, and D) are activities that can be accomplished alone, without peer interaction. Correct Answer(s): B

46. A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? The mother is A) regressing to an earlier behavior pattern. B) sublimating her anger. C) projecting her feelings onto the nurse. D) suppressing her fear.

Projection is attributing one's own thoughts, impulses, or behaviors onto another--it is the mother who is probably harming the child and she is attributing her actions to the nurse (C). The mother may be immature, but (A) is not the best description of her behavior. (B) is substituting a socially acceptable feeling for an unacceptable one. These are not socially acceptable feelings. The mother may be suppressing her fear (D) by displaying anger, but such an interpretation cannot be concluded from the data presented. Correct Answer(s): C

21. A 30-year-old sales manager tells the nurse, "I am thinking about a job change. I don't feel like I am living up to my potential." Which of Maslow's developmental stages is the sales manager attempting to achieve? A) Self-Actualization. B) Loving and Belonging. C) Basic Needs. D) Safety and Security.

Self-actualization is the highest level of Maslow's development stages, which is an attempt to fulfill one's full potential (C). (B) is identifying support systems. (C) is the first level of Maslow's developmental stages and is the foundation upon which higher needs rest. Individuals who feel safe and secure (D) in their environment perceive themselves as having physical safety and lack fear of harm. Correct Answer(s): A

54. A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with A) dissociative disorder. B) obsessive-compulsive disorder. C) panic disorder. D) post-traumatic stress syndrome.

Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness, which is the definition of a dissociative disorder (A). (B) is characterized by persistent, recurrent intrusive thoughts or urges (obsessions) that are unwilled and cannot be ignored, and provoke impulsive acts (compulsions) such as handwashing. (C) is an acute attack of anxiety characterized by personality disorganization. (D) is re-experiencing a psychologically terrifying or distressing event that is outside the usual range of human experience, such as war, rape, etc. Correct Answer(s): A

15. The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam? A) Acute psychiatric illnesses impair intelligence. B) Intelligence is influenced by social and cultural beliefs. C) Poor concentration skills suggests limited intelligence. D) The inability to think abstractly indicates limited intelligence.

Social and cultural beliefs (B) have significant impact on intelligence. Chronic psychiatric illness may impair intelligence (A), especially if it remains untreated. Limited concentration does not suggest limited intelligence (C). Difficulties with abstractions are suggestive of psychotic thinking (D), not limited intelligence. Correct Answer(s): B

65. A 72-year-old female client is admitted to the psychiatric unit with a diagnosis of major depression. Which statement by the client should be of greatest concern to the nurse and require further assessment? A) I will die if my cat dies. B) I don't feel like eating this morning. C) I just went to my friend's funeral. D) Don't you have more important things to do?

Sometimes a client will use an analogy to describe themselves, and (A) would be an indication for conducting a suicide assessment. (B) could have a variety of etiologies, and while further assessment is indicated, this statement does not indicate potential suicide. Normal grief process differs from depression, and at this client's age peer/cohort deaths are more frequent, so (C) would be within normal limits. (D) is an expression of low self-esteem typical of depression. (B, C, and D) are examples of decreased energy and mood levels which would negate suicide ideation at this time. Correct Answer(s): A

A nurse is caring for a client who is delusional and talking about people who are plotting to do harm. The staff members notice that the client is pacing more than usual, and the primary nurse concludes that the client is beginning to lose control. What is the most therapeutic nursing intervention? 1 Moving the client to a quiet place 2 Urging the client sit down for a short time 3 Encouraging the client to use a punching bag 4 Allowing the client to continue pacing under supervision

1 Clients losing control feel frightened and threatened; they need external controls and a reduction in external stimuli. The client will be unable to sit at this time; the agitation is building. Encouraging the client to use a punching bag is helpful for pent-up aggressive behavior but not for agitation associated with delusions. The pacing is not adequately relieving the client's agitation. Another intervention is needed to prevent acting-out behaviors.

A nurse educator is leading a class on supporting middle-aged adults who are experiencing midlife crises. What should the nurse include as the most significant factor in the development of this type of crisis? 1 The perception of their life situation 2 Many role changes that alter their experiences at this time 3 The anticipation of negative changes associated with old age 4 Lack of support from family members who are busy with their own lives

1 The most significant factor in either precipitating or avoiding a crisis is not the events but how the individual perceives them. Changes in role may occur, but, again, the individual's perception of these changes is most influential. The anticipation of negative changes associated with old age may be a factor, but perception is most important. Lack of support from family members is not a significant factor; the family may provide support, yet a crisis may still occur.

A woman who was sexually assaulted by a stranger in the elevator of her apartment building is brought by her husband to the emergency department. What is the priority nursing intervention? 1 Obtaining information about her perception of the incident 2 Notifying legal authorities that a sexual assault has occurred 3 Talking with the husband about his feelings concerning sexual assault 4 Teaching the client how to obtain a midstream clean-catch urine specimen

11 In a crisis situation it is important for the individual to talk about the situation to enable her to move past shock and disbelief. Notifying the legal authorities that a sexual assault has occurred is the client's decision. Although the nurse might talk with the husband, the priority is the woman not the husband. Teaching the client how to obtain a midstream clean-catch urine specimen is contraindicated because the use of water or an antiseptic solution during the procedure will wash away sperm or blood evidence.

A client is found to have a mood disorder, hypomanic episode. To support the diagnosis, the nurse should identify the signs and symptoms associated with this disorder. Select all that apply. 1 Distractibility 2 Flight of ideas 3 Low self-esteem 4 Increased need for sleep 5 Psychomotor retardation

12 These individuals have a short attention span; their attention is easily drawn to unimportant or irrelevant external stimuli. These individuals shift from one idea or topic to another and express their thoughts in a rapid flow of speech. These individuals have an inflated self-esteem or grandiosity. These individuals have a decreased need for sleep. These individuals have psychomotor agitation or an increase in goal-directed activity.

A hospitalized client with a mood disorder begins to be less hyperactive and acts calmer. One day the client says to the nurse, "My partner and I have problems getting along. Sometimes we don't see eye to eye." What are the nurse's most therapeutic responses? Select all that apply. 1 "Tell me more about how you see things differently." 2 "It can be very upsetting to be at odds with your partner." 3 "You're showing progress because you appear calmer today." 4 "Let's talk about a specific time when you didn't see eye to eye." 5 "It must be difficult living with a person who doesn't see things your way."

124 Asking the client to explain how she sees things differently is a therapeutic response; it asks the client to clarify and explain. "It can be very upsetting to be at odds with your partner" is an acceptable response because it focuses on the client's implied feelings. "Let's talk about a specific time when you didn't see eye to eye" is a therapeutic response because it asks the client to focus on more specific details. Noting that the client is showing progress changes the subject; it is better to continue discussing the same subject. The response "It must be difficult living with a person who doesn't see things your way" is judgmental.

When presenting a workshop on adolescent suicide, a community health nurse identifies risk factors. Select all that apply. 1 Victim of family violence 2 Limited or strained family finances 3 Member of a single parent household 4 Dependence on alcohol, drugs, or both 5 Uncertainty related to sexual orientation 6 Repeated demonstration of poor impulse control

1456 Being a victim of family violence of any kind increases the risk of suicide. Alcohol or drug abuse is a significant factor in adolescent suicide. A concern about sexual orientation or being accepted as homosexual is a risk factor for suicide, especially among adolescents. Poor impulse control can lead to an increased tendency toward risk-taking, which is a factor in suicide, especially among adolescents. Although economic problems and absence of a parent can both stress a family and its members, there is no research to support that either is a major factor in adolescent suicide.

A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply. 1 Chronic stress 2 Severe anxiety 3 Generalized pain 4 Excessive caffeine 5 Chronic depression 6 Environmental noise/distractor

146Acute or primary insomnia is caused by emotional or physical stress not related to the direct physiologic effects of a substance or illness. Excessive caffeine intake can cause disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and emotional discomfort and is therefore related to primary insomnia. Severe anxiety is usually related to a psychiatric disorder and therefore causes secondary insomnia. Generalized pain is usually related to a medical or neurologic problem and therefore causes secondary insomnia. Chronic depression is usually related to a psychiatric disorder and therefore causes secondary insomnia.

A man has completed an alcohol detoxification program and is setting goals for rehabilitation. When setting goals it is important for this client to understand the need to: 1 Restructure his life without alcohol. 2 Plan to avoid people who drink. 3 Accept that he is a fragile person. 4 Develop new social drinking skills.

1Clients must learn new lifestyles and coping skills to maintain sobriety. Planning to avoid people who drink is an unrealistic, unattainable plan. Accepting that he is a fragile person is judgmental, negative thinking that will lower self-esteem. Abstinence is essential; social drinking is not an option.

During a group discussion of the local news, a client asks how the nurse feels about the events in question. What is the best response by the nurse? 1 Providing a brief answer and redirecting the focus of the conversation 2 Exploring why the client wants to know this information 3 Reminding the client that the nurse's feelings are not the client's concern 4 Explaining personal views on the subject and asking the other clients what they think

1The nurse should answer briefly but then redirect the conversation to keep the focus on the client. Exploring why the client wants to know this information avoids the client's question and will cut off the discussion. Reminding the client that the nurse's feelings are not the client's concern is too abrupt and will cut off the discussion. Explaining personal views on the subject and asking the other clients what they think moves the focus to the nurse's opinions rather than the client's feelings.

What medication should the nurse expect to administer to actively reverse the overdose sedative effects of benzodiazepines? 1 Lithium 2 Flumazenil 3 Methadone 4 Chlorpromazine

2 2 Flumazenil (Romazicon) is the drug of choice in the management of overdose when a benzodiazepine is the only agent ingested by a client not at risk for seizure activity. Flumazenil medication competitively inhibits activity at benzodiazepine recognition sites on γ-aminobutyric acid-benzodiazepine receptor complexes. Lithium is used in the treatment of mood disorders. Methadone is used for narcotic addiction withdrawal. Chlorpromazine is contraindicated in the presence of central nervous system depressants.

A delirious client sees a design on the wallpaper and perceives it as an animal. How should a nurse communicate what the client perceived in the change-of-shift report? 1 A delusion 2 An illusion 3 A hallucination 4 An idea of reference

2 An illusion is a misperception or misinterpretation of an actual external stimulus. A delusion is a false belief that cannot be changed even by evidence; it is associated with psychosis. A hallucination results from an imaginary, not real, stimulus. An idea of reference is a belief that others are talking about the person.

When being admitted to a mental health facility, a young male adult tells the nurse that the voices he hears frighten him. The nurse knows that clients tend to hallucinate more vividly: 1 Before meals 2 After going to bed 3 During group activities 4 While watching television

2 Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions. Before meals, during group activities, and during television watching are all times of relatively high, competing environmental stimuli.

A nurse is caring for a hyperactive, manic client who exhibits flight of ideas and is not eating. What may be the reason why the client is not eating? 1 Feels undeserving of the food 2 Is too busy to take the time to eat 3 Wishes to avoid others in the dining room 4 Believes that there is no need for food at this time

2 Hyperactive clients frequently will not take the time to eat because they are overinvolved with everything in their environment. Feeling undeserving of the food is characteristic of a depressive episode. The client is unable to sit long enough with the other clients to eat a meal; this is not conscious avoidance. The client probably gives no thought to food because of overinvolvement with the activities in the environment.

A 65-year-old client is receiving amitriptyline (Elavil). What is the most important recommendation for the nurse to make to this client concerning this medication? 1 Obtain a complete cholesterol and lipid profile. 2 Have an eye examination to check for glaucoma. 3 Check the temperature daily for nighttime increases. 4 Assess for excessive sweating and possible weight loss.

2 In addition to baseline laboratory tests an older adult should have an eye examination with glaucoma testing when taking amitriptyline (Elavil). Amitriptyline causes dilation of the pupil (mydriasis), which interferes with drainage of aqueous humor through the canal of Schlemm. Interfering with the outflow of aqueous humor will increase intraocular pressure and may cause a progressive loss of vision in clients with glaucoma. Amitriptyline does not affect cholesterol production or temperature regulation. Amitriptyline does not cause excessive perspiration or weight loss, but it can increase appetite, especially for sweets, resulting in weight gain.

A male nurse is caring for a client. The client states, "You know, I've never had a male nurse before." What is the best reply by the nurse? 1 "Does it bother you to have a male nurse?" 2 "How do you feel about having a male nurse?" 3 "There aren't many male nurses; we're a minority." 4 "You sound upset. I'll get a female nurse to care for you."

2 Inquiring neutrally about the client's feelings about having a male nurse encourages the client to express and explore feelings in an open, nonjudgmental way. Asking the client whether having a male nurse is disturbing puts the client on the defensive. Stating that there aren't many male nurses does not encourage further conversation, and the client will not have the opportunity to express feelings; this response is focused on the nurse rather than on the client. Immediately volunteering to get a female nurse puts the client on the defensive rather than encouraging verbalization of feelings.

A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? Select all that apply. 1 Describes how others have caused the addiction 2 Verbalizes difficulty identifying personal strengths 3 Expresses uncertainty about meeting with the nurse 4 Acknowledges the effects of the addiction on the family 5 Addresses how the addiction has contributed to family distress

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Which client statement supports the diagnosis of somatic delusions? 1 "The government has assigned a team of assassins to kill me because I know too much." 2 "My heart stopped beating 3 days ago, and now my lungs are rotting away." 3 "I wear this coat all the time to keep them from x-raying my organs" 4 "The president of France and I will be announcing our engagement soon."

2A somatic delusion is a belief that the body is changing or behaving in an unusual way (e.g., the client's heart stopping and the lungs rotting away). Erotomanic delusions are focused on the belief that another person (usually famous or otherwise unattainable) is romantically interested in the client. Control delusions center on the belief that others are attempting to control or affect the person in some manner. Persecutory delusions involve beliefs that one is being singled out for harm.

At a staff meeting, while discussing the return of one of the staff nurses from a drug rehabilitation program, one nurse states, "I don't know why we are wasting time on this. We all know that addicts go back to using drugs as soon as the pressure increases." What is the nurse manager's best response? 1 "It's hard, but it is our professional obligation to work with these individuals." 2 "It's important for us to share our feelings about staff members with problems." 3 "I guess you feel somewhat guilty that you failed to recognize that this nurse was addicted." 4 "I don't think you should work with this staff member, because you have such negative feelings."

2Unless staff can share both positive and negative feelings, resentment, anger, and frustration may develop. The response "It's hard, but it is our professional obligation to work with these individuals" does little to foster communication and positive relationships among staff members. The responses "I guess you feel somewhat guilty that you failed to recognize that this nurse was addicted" and "I don't think you should work with this staff member, because you have such negative feelings" attack the speaker and cut off communication in the group.

Two weeks after a client has been admitted to the mental health hospital, the client's depression begins to lift. The nurse encourages involvement with unit activities, primarily because this type of activity: 1 Supports self-confidence 2 Provides for group interaction 3 Limits opportunities for suicide 4 Allows verbalization of repressed feelings of hostility

2\Group interaction provides a sense of belonging and fosters the assumption of responsibility. The group is not the best arena for the expression of repressed hostility. Support of self-confidence and limitation of opportunities for suicide are not ensured by group interaction. `

A client on the psychiatric unit tells the nurse, "I'm a movie star, and the other clients are my audience." What is an appropriate conclusion for the nurse to document about what the client is experiencing? 1 Flight of ideas 2 Idea of reference 3 Delusion of grandeur 4 Auditory hallucination

3 A delusion of grandeur is a fixed false belief that the person is a powerful, important person. A flight of ideas is an increase in the speed of thinking causing the person to shift from one idea to another without completing the previous idea; it is often expressed with pressured speech. An idea of reference is an incorrect interpretation of an external event as having a special meaning to the person. An auditory hallucination is experienced when a person hears voices without external stimuli.

How can a nurse in the mental health clinic best prepare a client for termination of their therapeutic relationship? 1 Periodically summarizing the client's progress during the working phase 2 Stating that if the client feels it is necessary, their collaboration may be extended 3 Telling the client during their first meeting how long their entire therapeutic relationship will last 4 Encouraging an exploration of feelings during the termination phase about the relationship's ending

3 A first step in any therapeutic relationship is the setting of parameters, such as time, frequency, and duration, for meetings. Periodic summaries of the client's progress are part of the working phase of a therapeutic relationship and therefore not an initial intervention in the termination phase. The nurse should not deviate from the original contract. Termination issues should be dealt with before the termination phase begins.

A psychiatric nurse understands that a situational crisis usually resolves within: 1 1 to 4 days 2 2 to 3 weeks 3 1 to 2 months 4 2 to 6 months

3 A situational crisis is a sudden, unexpected event with which the individual is unable to cope using past coping behaviors; this time frame provides an opportunity for the individual to learn new coping behaviors. Two to 6 months is longer than the expected period within which a crisis should be resolved. One to 4 days and 2 to 3 weeks are both too short of periods for the individual to develop new, successful coping mechanisms.

A client with a history of chronic alcoholism is admitted to the mental health unit. What does the nurse identify as the cause of a client's use of confabulation? 1 Ideas of grandeur 2 Need to get attention 3 Marked loss of memory 4 Difficulty accepting the truth

3 Alcoholic clients have loss of memory and adapt to this by unconsciously filling in with false information areas that cannot be remembered. Ideas of grandeur do not occur in this disease. A need to get attention is unrelated to confabulation. These individuals are not purposely lying but instead are trying to cover memory losses.

A depressed client says, "I'm no good. I'm better off dead." What is the priority nursing intervention? 1 Responding, "I'll stay with you until you're less depressed." 2 Replying, "I think you're good; you should think about living." 3 Alerting the staff to schedule 24-hour observation of the client 4 Unobtrusively removing those articles that may be used in a suicide attempt

3 Alerting the staff to schedule 24-hour observation of the client is the most therapeutic approach to preventing suicide. A staff member also provides special attention to help the client meet dependency needs and reduce a self-defeating attitude. Replying, "I think you're good; you should think about living" negates the client's feelings and cuts off further communication. Promising to stay with the client until the depression eases is unrealistic because the nurse cannot be with the client constantly until the depression lifts. Although potentially hazardous objects should be removed, the priority is 24-hour observation of the client.

A nurse is caring for a client who has been experiencing delusions. According to psychodynamic theory, delusions are: 1 Precipitated by external stimuli 2 Subconscious expressions of anger 3 A defense against anxiety 4 The result of magical thinking

3 Delusions are a way the unconscious defends the individual from real or imagined threats. Magical thinking is the belief that one's thoughts and behaviors can control situations and other people. For example, having bad thoughts about someone can cause that person to die. This type of thinking is found in young children but is pathological in adults. Illusions are false interpretations of actual external stimuli. Delusions are precipitated by feelings of anxiety, not anger.

The psychiatrist is concerned that one of the clients receiving haloperidol (Haldol) may be developing neuroleptic malignant syndrome. When assessing the client for this syndrome, for which clinical manifestations should the nurse monitor the client? 1 Jaundice and malaise 2 Tremors and seizures 3 Diaphoresis and hyperpyrexia 4 Dry skin and hyperbilirubinemia

3 Diaphoresis and hyperpyrexia are the classic signs of neuroleptic malignant syndrome, which is caused by neuroleptic-induced blockage of dopamine receptors. Jaundice and malaise are side effects of haloperidol (Haldol), not neuroleptic malignant syndrome. Tremors and seizures and dry skin and hyperbilirubinemia are side effects of haloperidol, not neuroleptic malignant syndrome.

A 55-year-old man who has a long history of drug and alcohol abuse tells the nurse during an interview that he is taking ginkgo biloba. The nurse knows that ginkgo biloba is taken to treat: 1 Insomnia 2 Depression 3 Memory impairment 4 Anxiety and nervousness

3 Ginkgo biloba is an herb used to treat age-related memory impairment and dementia. It has not been shown to be effective in treating insomnia, depression, or anxiety.

A client with schizophrenia who has type II (negative) symptoms is prescribed risperidone (Risperdal). Which outcomes indicate that the medication has minimized these symptoms? Select all that apply. 1 There is less agitation. 2 There are fewer delusions. 3 More interest is shown in unit activities. 4 The client reports that the hallucinations have stopped. 5 The client performs activities of daily living independently.

35 Apathy is a common type II (negative) symptom; flat affect and lack of socialization are also common. A lack of interest in performing daily self-care activities is a common type II (negative) symptom. More interest in unit activities is a type I (positive) symptom. Fewer delusions is a type I (positive) symptom. The disappearance of hallucinations is a type I (positive) symptom.

A male client with paranoid schizophrenia wraps his legs in toilet paper, believing that this will protect him from deadly germs contaminating the floor. What is the best nursing intervention? 1 Limiting the client's access to toilet paper 2 Providing the client with antimicrobial soap 3 Explaining to the client why this action is ineffective 4 Talking with the client about anxiety that focuses on health

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A newly admitted client looks at but does not respond to the nurse. What is the most appropriate statement by the nurse? 1 "Maybe you'd prefer to be alone for now. I'll come back later so we can talk." 2 "I'm talking to you; you must be having trouble understanding what I'm saying." 3 "This is the mental health unit of the hospital. Let me tell you about the services we have for you." 4 "I'm here to offer you my help and tell you about the services available to you on the mental health unit."

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An adolescent on a mental health unit becomes hyperactive. In which activity should the nurse encourage the client to become involved? 1 Carving figures from wood 2 Embossing and lacing leather wallets 3 Stenciling designs on copper sheeting 4 Sanding and assembling wooden bookends

4 Activities that release tension and use energy can decrease anxiety. Carving requires too much concentration, and the client may use the tools in a self-injurious manner. Making wallets requires sitting still for prolonged periods and a dexterity that the client may find impossible at this time. Stenciling requires too much concentration.

A client being admitted for alcoholism reports having had alcoholic blackouts. The nurse knows that an alcoholic blackout is best described as: 1 A fugue state resembling absence seizures 2 Fainting spells followed by loss of memory 3 Loss of consciousness lasting less than 10 minutes 4 Absence of memory in relation to drinking episodes

4 Although the exact cause is unclear, alcoholic blackouts appear to result from responses of central nervous system cells to the substance. The individual does not have any type of seizure during the blackout. Fainting is not associated with the blackout. The individual loses memory but not consciousness.

The biggest problem for an older female client, immediately after the sudden death of her husband, will probably be her inability to cope with: 1 Finances 2 Loneliness 3 Estrangement 4 Anger

4 Anger at her husband for leaving her may make the client feel guilty for having these feelings. Financial security may or may not be a problem for this client. Loneliness is something she will have to cope with later, depending on her support system; it is not an immediate problem. Estrangement may be something that she will have to cope with later; it is not an immediate problem.

A nurse is teaching clients in a medication education group about side effects of medications. Which drug will cause a heightened skin reaction to sunlight? 1 Lithium 2 Sertraline 3 Methylphenidate 4 Chlorpromazine

4 Clients taking chlorpromazine should be instructed to stay out of the sun. Photosensitivity makes the skin more susceptible to burning. Photosensitivity is not a side effect of lithium, sertraline, or methylphenidate.

A client tells the nurse in the mental health clinic that the practitioner said that the cornerstone of therapy used in the clinic is cognitive therapy. The client asks what this therapy entails. What concept should the nurse explain as the basis of cognitive therapy? 1 "Unconscious feelings influence actions." 2 "People can act their way into a new way of thinking." 3 "Maladaptive behaviors will continue as long as they are reinforced." 4 "Negative thoughts can precipitate anxiety."

4 Cognitive therapy seeks to discover underlying thoughts that lead to feelings of depression and anxiety; also, it teaches the client to replace these thoughts with more positive, realistic thinking. The response "Unconscious feelings influence actions" reflects a psychoanalytical approach to treatment. The response "People can act their way into a new way of thinking" reflects a behavioral approach to treatment. The response "Maladaptive behaviors will continue as long as they are reinforced" reflects a behavioral approach to treatment.

A nurse is interviewing a client newly admitted to an outpatient program after withdrawal from alcohol. What behavior best indicates that the client has accepted that drinking is a problem? 1 Participates in scheduled counseling sessions 2 Volunteers to be a sponsor for another alcoholic 3 Apologizes to family members for causing distress 4 Attends Alcoholics Anonymous meetings daily

4 Daily attendance at AA meetings usually indicates an acceptance of the problem and a desire for help. Attendance at counseling sessions is helpful but is not specific to the problem of alcoholism. Clients with alcohol problems should not sponsor other clients until sobriety has been maintained for a long period. Clients with alcohol problems may say that they are sorry many times but still not take responsibility for their drinking problem.

A 70-year-old retired man has difficulty remembering his daily schedule and finding the right words to express himself. He is found to have dementia of the Alzheimer type. The nurse knows that symptoms of this disorder: 1 Occur fairly rapidly 2 Have periods of remission 3 Begin after a loss of self-esteem 4 Demonstrate a progression of disintegration

4 Dementias, such as that of the Alzheimer type, result from pathological changes of central nervous system cells, producing deterioration that is long-term and progressive. These changes involve cognitive, functional, and behavioral changes that reflect predictable stages (stage 1, mild; stage 2, moderate; stage 3, severe). The duration of Alzheimer disease is 3 to 20 years, with an average of 10 years. Symptoms of delirium, not dementia, develop rapidly as a result of derangements of cerebral metabolism and neurotransmission. Once neurons are destroyed, remissions are uncommon. Interpersonal events do not precipitate dementias.

nurse is assessing a client who has been emotionally immobilized since her husband requested a divorce and moved out of their home. What should be determined first by the nurse in the crisis intervention center? 1 Her relationship with her husband 2 Whether she is receptive to suggestions 3 How she plans to support herself financially 4 What the divorce means to the client

4 Determining the significance of the divorce to the client is a method of identifying the client's perception of the event; it is critical to adequate assessment and appropriate intervention. The client's relationship with her husband is secondary in importance and may divert attention from the client's perception of the problem and the significance of the divorce to the client. Receptivity to suggestions should be explored later in therapy (i.e., in the planning stage). Although financial concerns are important, they should not be the first topic addressed.

A nurse is teaching a class about child abuse. What defense mechanism most often used by the physically abusive individual should the nurse include? 1 Repression 2 Transference 3 Manipulation 4 Displacement

4 Displacement is a defense mechanism in which one's pent-up feelings toward a threatening person are discharged on less threatening others. Repression is the unintentional putting out of the mind unacceptable or troubling thoughts, desires, or experiences. Transference is a mechanism by which affects or emotional tones are shifted from one individual to another; it is unrelated to child abuse. Manipulation is a mechanism by which individuals attempt to manage, control, or use others to suit their own purpose or to gain an advantage; it is unrelated to child abuse.

A client receiving fluphenazine decanoate (Prolixin Decanoate) develops dystonia early during therapy. What medication does the nurse expect to be prescribed to reverse this side effect? 1 Nafarelin (Synarel) 2 Fluoxetine (Prozac) 3 Trandolapril (Mavik) 4 Benztropine (Cogentin)

4 Dystonia is an extrapyramidal side effect (EPS) of fluphenazine decanoate (Prolixin Decanoate). The anticholinergic benztropine (Cogentin) is used to reverse the signs and symptoms (e.g., oculogyric crisis, torticollis, retrocollis) of dystonia. Nafarelin (Synarel) is a gonadotropin that stimulates the release of luteinizing hormone and follicle-stimulating hormone. Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor antidepressant. Trandolapril (Mavik) is an angiotensin-converting enzyme inhibitor antihypertensive.

A nurse considers the cultural factors that may influence the development of eating disorders. The nurse recalls that eating disorders exist more frequently in: 1 Affluent families 2 European countries 3 Men rather than women 4 Industrialized societies

4 Eating disorders are prevalent in industrialized societies that have an abundance of food; affected individuals likely equate food with pleasure, comfort, and love and may have been nurtured, punished, or rewarded with food. Eating disorders occur in all socioeconomic groups. The incidence and prevalence of eating disorders around the world are similar in European countries, the United States, Canada, Mexico, Japan, Australia, and other Westernized countries with plentiful food supplies. Studies indicate that 95% to 99% of persons with eating disorders are women, not men.

What action should the nurse take when it becomes apparent that communication between the nurse and the client is consistently superficial? 1 Assessing the client's ability to understand the nurse's questions 2 Reinforcing to the client how important sharing is for successful recovery 3 Reviewing how the questioning techniques are being utilized by the client 4 Evaluating how actively the nurse has been listening to the client

4 Effective active listening is critical to the development of meaningful, therapeutic communication between the nurse and the client. A lack of effective listening on the part of the nurse often times results in superficial, ineffective communication. Although there may be situations when assessing the client's cognitive abilities, reinforcing the importance of effective communication, or reviewing communication skills is an appropriate intervention, there are other, more commonly observed barriers to effective therapeutic communication.

A nurse identifies the establishment of trust as a major nursing goal for a depressed client. How can this goal best be accomplished? 1 By spending a day with the client 2 By asking the client at least one question daily 3 By waiting for the client to initiate the conversation 4 By visiting frequently for short periods with the client each day

4 Frequent short visits with the client each day demonstrate to the client that the nurse feels that the client is worth spending time with and helps restore and build trust. Spending a day with the client may be impossible on a regular basis unless the client is potentially suicidal. Asking the client at least one question a day will do little to establish communication between the nurse and the client and may be seen as threatening. The depressed client may never speak to the nurse and, left alone, will withdraw even further.

A nurse is writing a plan of care in the medical record of a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs. An intermediate goal for this client is: 1 "The client will develop faith in his wife." 2 "The client will develop better self-control." 3 "The client will develop insight into his behavior." 4 "The client will develop feelings of self-worth."

4 Helping the client develop feelings of self-worth will reduce the client's need to use pathological defenses. Faith in his wife, or the lack of thereof, is not the basic underlying problem, merely a symptom of it. Self-control, or the lack thereof, is not the basic underlying problem, merely a symptom of it. Insight can develop only when the need to use the defense is reduced; this is a long-term goal.

A nurse understands that after the administration of alprazolam (Xanax) it is important to assess the client for side effects. Initially the nurse should: 1 Measure urine output. 2 Look for abdominal distention. 3 Check the size of the pupils frequently. 4 Check the blood pressure

4 Hypotension is a major side effect of alprazolam (Xanax) that occurs early in therapy. An alteration in urine output is not a common side effect; however, urine retention may occur after prolonged use. Abdominal distention is not a common side effect, but abdominal distention from constipation may occur after prolonged use. Blurred vision, not dilated pupils, may occur. Dilated pupils associated with central nervous system depression are not a common side effect, although they may occur with overdose or prolonged use.

Which is the most important assessment data for a nurse to gather from the client in crisis? 1 The client's work habits 2 Any significant physical health data 3 A history of emotional problems in the family 4 The client's perception of the circumstances surrounding the crisis

4 Knowing the client's perception of the circumstances surrounding the crisis helps the nurse determine what the situation means to the client. Work habits, physical health information, and family history of emotional problems should be included in a later assessment, but none is the priority at this time.

A practitioner prescribes routine checks of the client's lithium level to be performed. How many hours after the last dose of lithium should the nurse plan to obtain the blood specimen? 1 2 to 4 2 4 to 6 3 6 to 8 4 8 to 12

4 Lithium absorption and excretion occur 8 to 12 hours after the last dose. Concentrations may be falsely higher at 2 to 4, 4 to 6, or 6 to 8 hours after administration, affecting the reliability of the readings.

As the nurse considers a client's placement on the continuum of anxiety, a key in determining the degree of anxiety being experienced is the client's: 1 Memory state 2 Creativity level 3 Delusional system 4 Perceptual field

4 Perceptual fields are a key indicator of anxiety level because the perceptual fields narrow as anxiety increases. Memory state, creativity level, and delusional system are not related directly to anxiety level.

A client begins fighting and biting other clients. The practitioner prescribes a stat injection of haloperidol (Haldol). How should the nurse implement this prescription? 1 Before the client realizes what is happening 2 After the client agrees to receive the injection 3 Quietly, without any explanation of the reason for it 4 Quickly, with an attitude of concern

4 Quickness is used for safety; an attitude of concern may help reduce the client's anxiety. The client must be told why sedation is being used; to do so surreptitiously will reduce the client's trust. A client who is this upset will not agree to a sedative; the client may harm himself or others and must be sedated. The client must be told why sedation is being used; to administer the medication surreptitiously will decrease trust.

A client is scheduled for a 6-week electroconvulsive therapy (ECT) treatment program. What intervention is important during the course of treatment? 1 Provision of tyramine-free meals 2 Avoidance of exposure to the sun 3 Maintenance of a steady sodium intake 4 Elimination of benzodiazepines for nighttime sedation

4 The use of benzodiazepines can raise the seizure threshold, which is counterproductive. A tyramine-free diet is required with monoamine oxidase therapy, not after ECT. Photosensitivity is not a side effect of ECT. A stable sodium level is necessary with lithium therapy, not ECT.

A nurse is teaching a client and family about the characteristics of dementia of the Alzheimer type. What physiological characteristic should the nurse include? 1 Periodic exacerbations 2 Aggressive acting-out behavior 3 Hypoxia of selected areas of brain tissue 4 Areas of brain destruction called senile plaques

4 When an older person's brain atrophies, some unusual deposits of iron are scattered on nerve cells. Throughout the brain, areas of deeply staining amyloid, called senile plaques, can be found; these plaques represent the end stage of destruction of brain tissue. Periodic exacerbations are associated with chronic deterioration, not with remissions and exacerbations. Aggressive acting-out behavior may or may not be part of the disorder. Hypoxia of selected areas of brain tissue is typical of vascular dementia, not dementia of the Alzheimer type.

A client has been attending weekly outpatient psychotherapy sessions for several months. The nurse psychotherapist has been working with the client to help lessen obsessive-compulsive behaviors that have interfered with the client's work performance. What information about the client best validates the client's improvement? 1 She states that she spends less time on ritualistic behaviors while at work. 2 She discusses techniques she uses to provide distraction from obsessive thoughts. 3 She reports spending an increased amount of time with friends in pleasurable activities. 4 She receives a letter from a supervisor at work stating that her job performance has improved.

4The letter provides objective validation that the client's work performance has improved. Although spending less time at work on compulsive behavior, coming up with techniques to lessen the need for the behavior, and spending more time with friends in pleasurable activities are all acceptable outcomes of therapy, they all represent subjective information reported by the client.

A nurse is conducting a therapy group whose objectives are to assist the members to gain insight and to change behavior so they are able to participate in life in a more satisfying manner. What leadership style will best help the nurse achieve these objectives? 1 Democratic, guiding 2 Hierarchal, directing 3 Autocratic, controlling 4 Laissez-faire, observing

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A nurse manager notices that a previously effective nurse appears to be distracted, at times forgets to document changes in clients' status, and rarely completes the required workload without help from another nurse. What should the nurse manager say to the nurse? 1 "You seem to be having difficulty completing your assignments. What can I do to help?" 2 "Why are you having trouble fulfilling your assignment? I need to know what's going on." 3 "Call me to help you organize your day—then you'll have time to complete your assignment." 4 "I've noticed that you always give part of your workload to another nurse. This is unacceptable."

1

A nurse on the psychiatric unit is conducting group therapy with clients who have diagnoses of polydrug abuse. This is a closed group. Four sessions have been held, and the group is now in the working phase. Which strategy is most beneficial for the nurse facilitator to use during the next session? 1 Providing a balance between support and skillful therapeutic confrontation 2 Continuing to be a supportive role model by using approved leadership behaviors 3 Teaching about the effects of drugs and alcohol on the body by using educational materials 4 Encouraging the group to rotate the leadership role among group members to enhance their self-esteem

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A young client who has become a mother for the first time is showing signs of being anxious about her new parenting role. With the nurse's encouragement, she joins the new mothers' support group at the local YMCA. What kind of prevention does this activity reflect? 1 Primary prevention 2 Tertiary prevention 3 Secondary prevention 4 Therapeutic prevention

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To help establish a therapeutic nurse-client relationship, the mental health nurse uses various communication techniques to convey a willingness to listen and a genuine desire to view the client and his or her needs in a respectful manner. What is the primary underlying principle guiding this process? 1 Caring is the underlying component of nursing that promotes client care. 2 Understanding of the psychosocial effects of a specific mental illness is vital to client care. 3 Each client has a right to appropriate care directed towards both the client's strengths and weaknesses. 4 The nurse initiates and maintains the nurse-client relationship so as to be therapeutic in its nature.

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A staff member tells a nurse that an older client becomes irritable when asked to assist with activities of daily living. On what general information about older adults should the nurse base a response? 1 Decreased ability to cope 2 Loss of ability to cooperate 3 Ambivalence toward authority 4 Difficulty performing step procedures

1 Fears and anxieties about themselves and their possessions are common in older adults because of a decreased self-concept and an altered body image; these changes result in a decreased ability to cope. Aging need not necessarily bring about a loss of one's ability to cooperate. The attitude of older adults concerning authority or others in their environment is set; indecision about life situations may be a result of insecurity. Difficulty performing step procedures is noted in the middle stage of Alzheimer disease; usually it is not observed in older adults. Topics

The Healthy People 2010 initiative has identified the reduction of suicide, increased services to adults with schizophrenia and those housed in jails and prisons, and increased culturally competent services as mental health goals. Though it is a valuable service, The Healthy People 2010 initiative has not identified physical care of the mentally ill as a mental health goal.

1 The individual who can reflect on life and accept it for what it was and is able to adjust and enjoy the changes retirement brings is less likely to experience health problems, especially stress-related health problems. Most emotionally healthy older adults do not focus on death. The changes of aging are usually not reversible. Dependency often is more threatening to this age group.

A nurse is caring for several clients who are going through withdrawal from alcohol. The primary reason for the ingestion of alcohol by clients with a history of alcohol abuse is that they: 1 Are dependent on it 2 Lack the motivation to stop 3 Have no other coping mechanism 4 Enjoy the associated socialization

1 Alcohol causes both physical and psychological dependence; the individual needs and depends on the alcohol to function. The theory that alcoholics have no other coping mechanism is a myth that often is associated with alcoholism; the individual needs to learn how to use other coping mechanisms more consistently and effectively. People with alcoholism commonly drink alone or feel alone in a crowd.

Within a few hours of alcohol withdrawal the nurse should assess the client for the presence of: 1 Irritability and tremors 2 Yawning and convulsions 3 Disorientation and paranoia 4 Fever and profuse diaphoresis

1 Alcohol is a central nervous system depressant; these responses are the body's neurological adaptation to the withdrawal of alcohol. Tachycardia, irritability, and tremors are the early signs of withdrawal and will appear 24 to 48 hours after the last ingestion of alcohol. Delirium (paranoia and disorientation) is not an early signs of alcohol withdrawal and occurs 48 to 72 hours after 48 to abstinence. Convulsions (delirium tremens, or DTs) are a later sign of severe withdrawal that occurs with alcohol withdrawal delirium. Fever and diaphoresis may occur during prolonged periods of delirium and are a result of autonomic overactivity. Yawning occurs with heroin withdrawal.

Grief reactions to the impending loss and security present in the one-to-one relationship should be anticipated. Testing behaviors occur early in the one-to-one relationship, not at termination. There should not be a disintegration of the personality (splitting). Manipulative behavior may occur in the early phase of a working relationship.

1 Allowing the client to be involved with decision-making promotes a feeling of control. Jointly setting limits on the frequency of the ritual will help prevent injury to the client's skin. A ritual is used as a defense against anxiety. Preventing the client from performing the ritual (locking the door to the bathroom) will increase his anxiety. Keeping him actively involved in projects in the facility is incorrect because rarely can a client with obsessive-compulsive disorder be distracted from a compulsive ritual. If the nurse does not intervene and allows the client to wash his hands as many times as he wants, serious impairment of skin integrity could develop.

A client is admitted to the psychiatric unit for severe depression with the potential for suicide. What is the most therapeutic nursing intervention when the client becomes more energized and communicative? 1 Continuing to assess the client at regular intervals 2 Encouraging the client to participate in group activities 3 Giving the client more autonomy to decide about privileges 4 Starting to teach the client about medications in preparation for discharge

1 Although the client appears to be improving, the possibility of suicide is still present because the client's physical and psychic energy has increased. Although the client may now be able to participate more fully in groups, the safety issue of monitoring the client's mood and actions is the priority. It is too soon to increase privileges; the client's increase in physical and psychic energy may permit the client to act on suicidal thoughts. Teaching the client about medications in preparation for discharge should have been included in the initial plan of care.

Thirty minutes after administering fluphenazine (Prolixin) to a client, the nurse notes that the client's jaw is rigid, the client is drooling, and her speech is slurred. There are a number of as-needed prescriptions in the client's chart. What should the nurse administer? 1 Benztropine (Cogentin), 2 mg intramuscularly 2 Diazepam (Valium), 10 mg by mouth 3 Trihexyphenidyl (Artane), 1 mg by mouth 4 Haloperidol (Haldol), 2 mg intramuscularly

1 Benztropine (Cogentin) is an anticholinergic, antiparkinsonian drug used to treat drug-induced extrapyramidal symptoms associated with phenothiazine therapy; the intramuscular (IM) route will relieve symptoms more rapidly. Haloperidol (Haldol) is also an antipsychotic and may produce parkinsonism, not relieve it. Diazepam (Valium) is not effective in reducing extrapyramidal side effects. Although trihexyphenidyl (Artane) is an appropriate medication, swallowing pills may be difficult for the client; the oral medication should not be administered.

What assessment of a group member does the nurse use to identify the emotional-informal leader of the group? 1 Reflects the feeling tone of the group 2 Designates the roles within the group 3 Has an authoritarian role within the group 4 Selects those who are to be members of the group

1 By sensing, supporting, and verbalizing the emotional feelings of others, an individual emerges as the leader. The group members designate roles themselves. An authoritarian role is filled by many group leaders, but it does not permit focus on emotions or feelings. Selection of group members may be done by many people in various ways.

A hospitalized 7-year-old boy wakes up crying because he has wet his bed. It is most appropriate for the nurse to: 1 Change the child's bed while he changes his pajamas. 2 Allow the child to change his bed and pajamas. 3 Take the child to the bathroom and change his pajamas. 4 Remind the child to call the nurse next time to avoid the need to change his pajamas.

1 Changing the child's bed while the child changes his pajamas will not call attention to the accident and will minimize the child's embarrassment. The child would probably be unable to change the bed without assistance; failure to complete the task might add to his embarrassment. Taking the child to the bathroom to change his pajamas and reminding the child to call a nurse next time will only add to the child's embarrassment.

Which paired drugs does the nurse expect the practitioner to prescribe for a client admitted for acute alcohol detoxification? 1 Chlordiazepoxide (Librium) and thiamine 2 Clonidine (Catapres) and propranolol (Inderal) 3 Buprenorphine (Subutex) and naloxone (Narcan) 4 Chlorpromazine (Thorazine) and disulfiram (Antabuse)

1 Chlordiazepoxide (Librium) is used to prevent seizures and to lower vital signs during alcohol detoxification. Thiamine is used to lessen the Wernicke-Korsakoff symptoms of alcohol withdrawal. Clonidine (Catapres) and propranolol (Inderal) will lower vital signs during alcohol withdrawal but will not help prevent seizures. Buprenorphine (Subutex) and naloxone (Narcan) are indicated for the treatment of opioid withdrawal. Chlorpromazine (Thorazine) is contraindicated because it lowers the seizure threshold. Disulfiram is used to maintain alcohol abstinence.

A client describes his delusions in minute detail to the nurse. How should the nurse respond? 1 By changing the topic to reality-based events 2 By continuing to discuss the delusion with the client 3 By getting the client involved in a social project with peers 4 By disputing the perceptions with the use of logical thinking

1 Decreasing time spent on delusions prevents reinforcement of psychotic thinking. Discussing reality-based events improves contact with reality. Challenging the client may increase anxiety. The client will have difficulty getting involved in a social activity; the activity will not stop the delusion. Encouraging discussion will give validity to the delusion.

A nurse is working with a client who has emotional problems. During what stage of the therapeutic nurse-client relationship does the nurse anticipate that most of the client's problem-solving will occur? 1 Working stage 2 Planning stage 3 Orientation stage 4 Termination stage

1 During the working stage, goals are met, problems are resolved, and changes in behavior occur. There is no such thing as the planning stage in the nurse-client relationship; this is a step in the nursing process. During the orientation stage, trust is the primary focus, goals and contracts are set, and problems are identified. The termination stage is focused on accomplishments, reinforces new behaviors, and closes the relationship.

During the eighth session of a therapy group, a member who talks frequently is interrupted by one who doesn't. When the interrupting person is finished talking, the one who usually contributes says, "I'm so glad that you feel like talking today." While saying this, the client sits rigidly and looks angry. How should the nurse respond? 1 Comment on the interrupted client's angry behavior and pleasant words. 2 State that it appears that these members of the group are not getting along. 3 Agree with the interrupted client that it is good to have the quiet client talk. 4 Ignore the comment and speak with the talkative member privately about being hostile.

1 For this to be a growth process for the group, feelings and behaviors must be explored. It is better to focus on behaviors and feelings than on personalities or the fact that they do not get along. Agreement ignores the covert message, which should be explored to help the client and the group. Commenting on the incongruent verbal and nonverbal behavior may lead to a growth experience for the client and the group.

A nurse begins terminating the consistent one-to-one relationship with a client who is soon to be discharged. How might the nurse expect the client to respond to the termination of their relationship? 1 Grief 2 Testing 3 Splitting 4 Manipulation

1 Grief reactions to the impending loss and security present in the one-to-one relationship should be anticipated. Testing behaviors occur early in the one-to-one relationship, not at termination. There should not be a disintegration of the personality (splitting). Manipulative behavior may occur in the early phase of a working relationship.

A client is admitted to the acute psychiatric unit of the local community hospital. The client is guarded and suspicious. After a thorough evaluation, a diagnosis of schizophrenia, paranoid type, is made. What initial approach should be used by the nurse assigned to establish a therapeutic one-to-one relationship with this client? 1 Casual and honest 2 Warm and friendly 3 Permissive and distant 4 Undemanding and watchful

1 Individuals with schizophrenia of the paranoid type are more apt to trust nurses who display matter-of-fact, predictable behaviors. The warm and friendly approach is too threatening to the individual with schizophrenia of the paranoid type, who does not trust others. The permissive and distant approach may be perceived as a lack of interest; these behaviors tend to reinforce a paranoid individual's social withdrawal. Watchful behavior on the part of the nurse reinforces a paranoid client's suspiciousness.

Survivors of a major earthquake are being interviewed on admission to the hospital. The nurse notes that they exhibit a flattened affect, make minimal eye contact, and speak in a monotone. These behaviors are indicative of the defense mechanism known as: 1 Isolation 2 Splitting 3 Introjection 4 Compensation

1 Isolation is the separation of thought or memory from feeling. Splitting is the polarization of positive and negative feelings. Introjection is the integration of the beliefs and values of another into one's own ego. Compensation is making up for a real or imagined lack in one area by overemphasizing another.

A client and the client's spouse are presented with electroconvulsive therapy (ECT) as a treatment option instead of pharmacotherapy after the client experiences adverse effects of medication therapy. The nurse meets with them to discuss the procedure. What should the nurse's first action be? 1 Allowing the client and family members to voice feelings, myths, and fantasies about ECT 2 Clarifying misconceptions and emphasizing the therapeutic value of the procedure for the depressed individual 3 Providing them with a brochure about the treatment and scheduling another time to review and answer their questions 4 Completing a detailed medical and psychiatric history and then starting family and client teaching at their level of comprehensio

1 It is most important for the nurse to facilitate a discussion of feelings before teaching because misconceptions about the presumed effects on the brain, public fears, and lack of accurate information regarding ECT precipitate anxiety. Anxiety interferes with learning. Misconceptions can be clarified only after they are expressed; citing the value of the procedure will be ineffective before fears and feelings are elicited. Although written material should be provided, this is not the first action. Depending on their readiness to learn, another meeting may be necessary to continue teaching. Although teaching should be client/family centered, a structured interview just before teaching will not set the climate for learning to occur.

Which activity is the least therapeutic for a severely depressed client? 1 Having the client select an activity 2 Simple short-term activity 3 Monotonous, repetitive activity 4 Specific activity to be followed

1 It is unreasonable to expect a severely depressed client to select an activity. Severely depressed clients are not motivated to take action or to plan ahead. They are unable to direct their energy toward the environment. If they do select an activity, it may be too difficult for them to complete. Simple short-term activities are helpful for a severely depressed client whose attention span is limited. Monotonous, repetitive activity is helpful to a severely depressed client because it requires little thought and provides gratification and satisfaction. A specific activity is helpful for a person who is experiencing depression or who is cognitively impaired.

A client with a history of alcohol abuse says to the nurse, "Drinking is a way out of my depression." Which strategy will probably be most effective for the client at this time? 1 A self-help group 2 Psychoanalytical therapy 3 A visit with a religious advisor 4 Talking with an alcoholic friend

1 Members of self-help groups, particularly Alcoholics Anonymous, are living with the problem themselves; therefore problem identification and self-responsibility are emphasized and manipulation is limited. Long-term therapy tends to increase anxiety until resolution occurs; level of commitment and duration of therapy render it a less desirable choice for substance abusers. Depending on the client's feelings about religion, talking with a religious advisor may or may not be helpful. Whether talking with an alcoholic friend will be useful depends on the friend's drinking status; it may be helpful or harmful. These variables negate the effectiveness of this choice.

A health care provider prescribes oxazepam (Serax) for a client who is beginning to experience withdrawal symptoms while undergoing detoxification. What are the primary reasons that oxazepam is given during detoxification? 1 Reduces the anxiety-tremor state and prevents more serious withdrawal symptoms 2 Prevents injury and protects the client when seizures occur 3 Enables the client to sleep and eat better during periods of agitation 4 Encourages the client to cooperate with and accept treatment for alcoholism

1 Oxazepam (Serax) potentiates the actions of γ-aminobutyric acid, especially in the limbic system and reticular formation and thus minimizes withdrawal symptoms. This drug helps reduce the risk for seizures but does not prevent injury or protect the client during a seizure. Enabling the client to sleep and eat better during periods of agitation is not the purpose of the drug. The ability of the client to accept treatment depends on the client's readiness to accept the reality of the problem.

A psychiatric nurse is hired to work in the psychiatric emergency department of a large teaching hospital. While reviewing the manuals, the nurse reads, "People with mental health emergencies shall be triaged within 5 minutes of entering the emergency department." What does the nurse consider this statement to represent? 1 Hospital policy 2 Standard of care 3 Hospital procedure 4 Mental Health Bill of Right

1 Policies are statements that help define a course of action; what is to be done is stated in policies, and how a task or skill is to be performed is defined in a procedure manual. Standards of care are published by the American Nurses Association; they reflect current knowledge and represent levels of practice agreed on by experts within the specialty; in legal terms, the standard of care is that level of practice that a reasonably prudent nurse would provide. A hospital procedure defines how a task or skill is to be performed. The Mental Health Bill of Rights states that all clients have the right to respectful care, confidentiality, continuity of care, relevant information, and refusal of treatment, except in an emergency or by law.

A client with an antisocial personality disorder is being admitted to a mental health unit. What information should the nurse include in this initial interview? 1 The unit's usual routines and rules 2 The language that is acceptable on the unit 3 A detailed explanation of the client's role on the unit 4 A list of the unit's staff members and their responsibilities

1 Providing the routines and rules will foster a feeling of security because the client will know what to expect and that the environment will be safe. Telling the client what language is inappropriate and may increase the client's anxiety and serve little purpose; necessary limits should be individually set when needed. A detailed explanation of the client's expected role is inappropriate and may increase the client's anxiety; there is no one prototype of a client's role. Providing a list of staff members and their responsibilities is inappropriate and may be somewhat overwhelming; the client should be introduced to the staff at the beginning of their interactions.

The nurse is planning therapeutic group sessions for regressed long-term clients. The nurse understands that these clients need to: 1 Experience a structured setting. 2 Learn how to confront interpersonal conflict. 3 Develop the sense that they can control the group. 4 Have opportunities for an expression of deep feelings.

1 Regressed long-term clients need structure and external controls to help organize their thought processes. These clients need gentle assistance to deal with conflict situations. Most regressed long-term clients would be too anxious to assume a leadership role. Such experiences are beyond the capability or psychological tolerance of these clients.

A female client has terminal cancer. Her family members are concerned because she appears to be accepting less and less responsibility for her own care. What should the nurse do to help family members plan for the client's care? 1 Encourage them to accept her regression until she can cope more effectively. 2 Explain that her anger is normal and identify ways to deal with the behavior. 3 Point out that denial is an expected response and generally is only temporary. 4 Assist them in identifying coping strategies to give her more control over the situation.

1 Regression to a more immature, helpless developmental level is not unusual and should be supported at this time. The client's behavior does not indicate anger. Denial is not the response described. The client's behavior is inconsistent with the need for more control.

A female client's stream of consciousness is occupied exclusively with thoughts of her mother's death. The nurse plans to help the client through this stage of grieving, which is known as: 1 Resolving the loss 2 Shock and disbelief 3 Developing awareness 4 Restitution and recover

1 Resolving a loss is a slow, painful, continuous process until a mental image of the dead person, almost devoid of negative or undesirable features, emerges. The shock-and-disbelief stage is usually dominated by a refusal to accept or comprehend the fact that a loved one has died. The reality of the death and its meaning as a loss, plus anger, dominate this stage. The various rituals of the funeral help to initiate the recovery or restitution stage.

A client is started on chlorpromazine (Thorazine). To prevent life-threatening complications from the administration of this medication to an anxious, restless client, it is important that the nurse: 1 Monitor the client's vital signs. 2 Provide adequate restraint. 3 Protect against exposure to direct sunlight. 4 Watch the client for extrapyramidal side effects.

1 Tachycardia, hyperpyrexia, and tachypnea are indications of neuroleptic malignant syndrome, which is a life-threatening complication. Restraint of any type may worsen the client's anxiety and result in struggling and increased agitation. Photosensitivity occurs most commonly when clients are taking large doses and are spending time outdoors in the sun, but it is not life threatening. Tardive dyskinesia usually results from prolonged large doses of phenothiazines in susceptible clients, but it is not life threatening.

A client with schizophrenia plans an activity schedule with the help of the treatment team. A written copy is posted in the client's room. What should the nurse say when it is time for the client to go for a walk? 1 "It's time for you to go for a walk now." 2 "Do you want to take your scheduled walk now?" 3 "When would you like to go for your walk today?" 4 "You're supposed to be going for your walk now.

1 Telling the client that it is time to take a walk is concise and does not require decision-making; it is therefore less likely to increase anxiety. "Do you want to take your scheduled walk now?" asks the client to make a decision when a refusal is unacceptable. Requiring the client to make a decision when acutely ill may increase anxiety; also, it permits the unacceptable answer of "never." "You're supposed to be going for your walk now" is somewhat accusatory; it may increase anxiety by placing responsibility on the client.

The nurse determines that the therapy that has the highest success rate for people with phobias is: 1 Desensitization involving relaxation techniques 2 Insight therapy to determine the origin of the fear 3 Psychotherapy aimed at rearranging maladaptive thought processes 4 Psychoanalytic exploration of repressed conflicts of an earlier developmental phase

1 The most successful therapy for people with phobias consists of behavior modification techniques involving desensitization. Insight into the origin of the phobia will not necessarily help the client overcome the problem. Psychotherapy aimed at rearranging maladaptive thought processes may increase understanding of the phobia but may not help the client cope with the fear; there is no maladaptive thought process associated with phobias. Psychoanalysis may increase understanding of the phobia but may not help the client cope successfully with the unreasonable fear.

While watching television in the dayroom a client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs from the room to the far end of the hallway. What is the most therapeutic intervention by the nurse? 1 Walking to the end of the hallway where the client is standing 2 Accepting the action as the impulsive behavior of a sick person 3 Asking another client in the dayroom why the client acted as she did 4 Documenting the incident in the client's record while the memory is fresh

1 Walking to the end of the hallway where the client is standing lets the client know that the nurse is available. It also demonstrates an acceptance of the client. Accepting the action as the impulsive behavior of a sick person is an avoidance technique; it shows a lack of acceptance of the client as a person. Another client's perception of the incident may or may not be valid. Although it is important to document the incident in the client's record, this does not take precedence over letting the client know the nurse is available if needed.

A nurse notes that a client in the detoxification unit is exhibiting early signs of alcohol withdrawal. What clinical manifestations might the nurse have noticed? Select all that apply. 1 Tremors 2 Anorexia 3 Agitation 4 Delusions 5 Confusion

12 Hand tremors, related to dysfunction of the nervous system, are an early sign of withdrawal from alcohol; alcohol depresses the central nervous system, interferes with nerve conduction, and results in peripheral neuropathy. Signs and symptoms of alcohol withdrawal begin within 12 hours of cessation or decrease in alcohol consumption, peak in 48 to 72 hours, and usually begin to ease after 4 or 5 days. Anorexia, nausea, and vomiting are early signs of withdrawal from alcohol; alcohol affects the gastrointestinal system and can cause gastritis, pancreatitis, hepatitis, and cirrhosis. Psychomotor agitation is a late, not an early, sign of alcohol withdrawal. Transient visual, auditory, and tactile hallucinations, rather than delusions, are associated with alcohol withdrawal. Confusion, disorientation, and impaired cognition are not early signs of alcohol withdrawal; alcohol withdrawal delirium occurs in less than 10% of those who experience the alcohol withdrawal syndrome.

A client with a diagnosis of schizophrenia, undifferentiated type, is being admitted to the psychiatric unit. What clinical manifestations does the nurse expect when assessing this client? Select all that apply. 1 Excited behaviors 2 Loose associations 3 Inappropriate affect 4 Feelings of depression 5 Hypervigilant behavior

123 Excited behaviors, such as aggressive hitting or biting, often are associated with an acute onset of undifferentiated schizophrenia. Loose association is a characteristic related to thought disorders such as schizophrenia, undifferentiated type. The affect usually is inappropriate, rather than flat, in undifferentiated schizophrenia. Depression is not characteristic of undifferentiated schizophrenia. Hypervigilant behaviors generally are associated with paranoid schizophrenia, not undifferentiated schizophrenia.

The nurse is admitting a client with a history of bipolar disorder. The nurse determines that the client is in the manic phase. Which signs and symptoms contribute to the nurse's conclusion? Select all that apply. 1 Irritability 2 Grandiosity 3 Pressured speech 4 Thought blocking 5 Psychomotor retardation

123 Irritability and emotional lability, fluctuating between euphoria and anger, are commonly associated with mania. An inflated self-esteem and delusions of grandeur represent mood-congruent psychotic features of mania; clients believe that they possess extraordinary talents, that they are famous, or that they know someone famous. They are extremely talkative and their speech is rapid, with an urgent quality (pressured speech); they rapidly change subjects and have flight of ideas and racing thoughts. Thought blocking occurs most often with schizophrenia; the client loses the train of thinking and is unable to retrieve the previous thought. Psychomotor retardation is related to depression; clients with mania move fast, pace, fidget, and are rarely still.

Certain questions are applicable in determining nursing negligence. Select all that apply. 1 "Was reasonable care provided?" 2 "Was there a breach of nursing duty?" 3 "Was there an act of omission that resulted in harm? 4 "Except for the nurse's action, would the injury have occurred?" 5 "Did the nurse fully understand the actions would result in harm?"

1234 Nursing negligence is described as the failure to do or not do what a reasonably careful nurse would do under the circumstances. The elements that must be present to determine negligence include whether the nurse fulfilled the legal duties to provide reasonable care and foresee a risk of injury under certain circumstances and whether there was a breach of duty and whether any injury resulted if there was a breach of duty. The intentional or unintentional nature of a behavior is determined by an understanding of the actions and their consequences.

A client who attempted suicide by slashing her wrists is transferred from the emergency department to a mental health unit. What important nursing interventions must be implemented when the client arrives on the unit? Select all that apply. 1 Obtaining vital signs 2 Assessing for suicidal thoughts 3 Instituting continuous monitoring 4 Initiating a therapeutic relationship 5 Inspecting the bandages for bleeding

12345Obtaining vital signs and inspecting the bandages for bleeding are interventions that must be performed in this situation; physiological stability must be maintained. Suicidal impulses take priority, and the client must be stopped from acting on them while treatment is in progress. A therapeutic relationship must be developed so the client can trust the nurse to provide a safe environment and aid her emotional recovery.

A nurse is making a home visit to a young male client manifesting chronic symptoms of AIDS. The nurse assesses the client for signs of altered mental health function associated with AIDS. Select all that apply. 1 Delusions 2 Memory loss 3 Hopelessness 4 Hyperactivity 5 Paranoid thinking

1235 Changes in the neurological system can lead to alteration in thought patterns, causing delusional and paranoid thinking. Over time, AIDS affects the central nervous system and leads to neurological problems such as deterioration of memory. Feelings of hopelessness commonly occur in clients with AIDS because of the chronic nature of the disorder. Hyperactivity is a condition in which the client has too much energy; clients with AIDS experience a decrease in energy.

A newly immigrated older Chinese adult is brought to a mental health clinic when family members become concerned that their parent is depressed. In an attempt to conduct a culturally competent assessment interview, the nurse asks certain questions. Select all that apply. 1 "What brought you here for treatment today?" 2 "What do you believe is the cause of your depression?" 3 "Does religion have a role in your perception of health and wellness?" 4 "Do you have insurance that includes coverage of mental health issues?" 5 "Have you ever sought treatment for a mental health problem previously?"

1235 Determining the client's perception of the problem is an appropriate question that allows culturally factors to be included. Encouraging the client to discuss her problems will facilitate a clearer understanding of the factors involved. Religion often plays a significant role in a client's view of health, wellness, and recovery. Knowing whether a client has ever undergone treatment for a mental health problem reveals mental health history and how previous issues were addressed. Insurance coverage is not pertinent to the issue and is an inappropriate topic of questioning by the nurse.

Which of the following interventions will assist in creating and maintaining a therapeutic environment on an acute care mental health unit? Select all that apply. 1 Reorienting clients to the rules of the unit whenever necessary 2 Providing a posted schedule of unit activities 3 Monitoring each client for the potential of aggressive behavior 4 Assuring the clients that they will have unlimited access to the telephone 5 Encouraging the clients to take an active role in planning the unit's activities

1235 Safety, structure, balance, and limit setting are elements that the nurse addresses when providing a therapeutic milieu. Privileges, such as telephone access, cannot be assured because they are earned and often are factors that are affected by the client's needs and behaviors.

The nurse is leading a relapse-prevention group for clients who experience bipolar disorder manic episodes. Which strategies should the nurse teach to help prevent or identify impending relapse? Select all that apply. 1 Watch for changes in libido. 2 Keep dietary changes to a minimum. 3 Maintain a regular sleeping schedule. 4 Plan multiple varied activities every day. 5 Monitor yourself for increased irritability or mood instability

1235Increased sex drive often indicates the beginning of a manic episode. Changes in the eating pattern can trigger a manic episode. Changes in the sleeping pattern may increase anxiety and trigger a manic episode. An elevated, expansive, or irritable mood often indicates the beginning of a manic episode. Too many activities may be too stimulating and precipitate a manic episode. Simple, repetitive routines should be followed to limit change or anxiety.

A 37-year-old man has been remanded by the court to the drug rehabilitation unit of a psychiatric facility for treatment of cocaine addiction. When taking his health history, what characteristics should the nurse expect the client to report? Select all that apply. 1 Anxiety 2 Weight loss 3 Palpitations 4 Sedentary habits 5 Difficulties with speech

123Cocaine, an alkaloid stimulant, can precipitate anxiety, hypervigilance, euphoria, agitation, and anger. The loss of appetite and increased metabolic rate associated with cocaine addiction both promote weight loss. Cocaine is a stimulant that has cardiac effects such as tachycardia and dysrhythmias. Sedentary habits are associated with barbiturate addiction. Difficulties with speech are associated with other addictions such as alcohol and methadone.

Sildenafil (Viagra) is prescribed for a man with erectile dysfunction. A nurse teaches the client about common side effects of this drug, which include which of the following? Select all that apply. 1 Flushing 2 Headache 3 Dyspepsia 4 Constipation 5 Hypertension

123Flushing is a common central nervous system response to sildenafil (Viagra). Headache is a common central nervous system response to sildenafil. Dyspepsia is a common gastrointestinal response to sildenafil. Diarrhea, not constipation, is a common gastrointestinal response to sildenafil. Hypotension, not hypertension, is a cardiovascular response to sildenafil. It should not be taken with antihypertensives and nitrates, because drug interactions can precipitate cardiovascular collapse.

A client in the early dementia stage of Alzheimer disease is admitted to a long-term care facility. Which activities must the nurse initiate? Select all that apply. 1 Weighing the client once a week 2 Having specialized rehabilitation equipment available 3 Keeping the client in pajamas and robe most of the day 4 Establishing a schedule with periods of rest after activities 5 Reviewing the client's weekly budget and use of community resources 6 Setting up a plan for weekly entertainment through a senior citizens group

124 Monitoring weight is an objective way to assess nutritional status. Specialized equipment can facilitate the client's participation in self-care. Incorporating rest periods into the client's day prevents fatigue and energizes the client for the next period of activity. The client needs to wear clothes to help maintain a positive view of self. It is not appropriate to review budgeting and use of community resources with a client in the early dementia stage of Alzheimer disease; these activities may produce frustration, withdrawal, or self-absorption. A client in the early dementia stage of Alzheimer disease is usually unable to participate in or travel with a senior citizen group.

Which nursing activities are specifically focused on achieving Healthy People 2010's mental health objectives? Select all that apply. 1 Providing suicide screening for a senior citizens group 2 Initiating outpatient services for homeless schizophrenic adults 3 Offering care for mental health clients with major health conditions 4 Teaching stress-management techniques to those housed in the local jail 5 Advocating for culturally competent mental health care within each state

1245 The Healthy People 2010 initiative has identified the reduction of suicide, increased services to adults with schizophrenia and those housed in jails and prisons, and increased culturally competent services as mental health goals. Though it is a valuable service, The Healthy People 2010 initiative has not identified physical care of the mentally ill as a mental health goal.

An older client is admitted to the hospital with the diagnosis of dementia of the Alzheimer type and depression. Which signs of depression does the nurse identify? Select all that apply. 1 Neglect of personal hygiene 2 Increased appetite 3 Loss of memory 4 "I don't know" answers to questions 5 "I can't remember" answers to questions

1245Neglect of personal hygiene is associated with depression because of low self-esteem. People who are depressed do not have physical or emotional energy; "I don't know" and "I can't remember" answers require little thought or decision-making. Patients with depression can either have decreased or increased appetite. Depression does not cause memory deficits.

A new employee orientation on the policies and procedures related to the therapeutic use of seclusion stresses that seclusion is contraindicated for certain clients. Select all that apply. 1 Suicidal 2 Cognitively impaired 3 Admitted involuntarily 4 Unwilling to agree to the intervention 5 Prone to unstable changes in cardiac status

125 A suicidal client requires close observation and is not an appropriate candidate for seclusion. A cognitively impaired client would likely suffer adversely from the low-stimulus environment of seclusion. Unstable physical or emotional conditions preclude the use of seclusion because the necessary monitoring would not be available. An involuntary commitment does not preclude the appropriate use of a therapeutic intervention such as seclusion. The client need not voluntarily agree to seclusion if the circumstances warrant the intervention.

parent of four is remanded to the psychiatric unit by the court for observation. The client was arrested and charged with abusing a 2-year-old son, who is in the pediatric intensive care unit in critical condition. The nurse approaches the client for the first time. How should the nurse anticipate that the client will likely respond? Select all that apply. 1 By denying beating the son 2 By avoiding talking about the situation 3 By expressing excessive concern for the son 4 By asking where the other three children are 5 By exhibiting an emotional response that is inconsistent with degree of injury

125 Denying the beating requires the parent to fabricate a story about how the physical injury occurred. The parent will often blame the child for the injury. In most instances, an abusive parent tries to avoid talking about the situation as a means of reducing guilt and repressing the action. Responses usually are inappropriate, exaggerated, or absent. Little concern is expressed for the child because this will require verbal expression and acceptance of the action. A parent's concern for the nonabused children without an expression of concern about the abused child documents a different feeling about the abused child, which the parent will try to avoid.

When caring for clients with the diagnosis of anorexia nervosa or bulimia nervosa, it is important that the nurse understand the sociocultural influences related to eating disorders in the United States. What are these influences? Select all that apply. 1 Diet industry 2 Fashion trends 3 Fast food industry 4 Over-the-counter medications 5 Competitive women's athletics

125 Weight management moved into the mainstream in the 1950s and increased its momentum with the fitness industry in the 1980s and 1990s. In the new century, women are constantly bombarded by the media with products and programs that are designed to help them attain the perfect body, which for most women is unrealistic. Since the 1960s the trend in fashion has been toward thinness, with fabrics that cling and styles that reveal the body. Print and movie media, including advertising, are focused on a thin, perfect ideal that is unattainable for most women. Several women's sports, such as gymnastics and figure skating, emphasize low body weights, and so does ballet. These demands may lead to eating disorders in girls and women who wish to compete. Although some people with bulimia nervosa may eat fast food, the fast food industry is unrelated to the origin of anorexia nervosa or bulimia nervosa. Although some people with eating disorders use over-the-counter medications, particularly laxatives, over-the-counter medications are unrelated to the origin of eating disorders.

The nurse interviews a young female client with anorexia nervosa to obtain information for the nursing history. What will the client's history most likely reveal? Select all that apply. 1 Ritualistic behaviors 2 Desire to improve her self-image 3 Supportive mother-daughter relationship 4 Low achievement in school and little concern for grades 5 Satisfaction with and a desire to maintain her current weight

12Clients with anorexia nervosa frequently have a history of ritualistic behaviors, rigidity, and meticulousness, reflecting a need for control. Clients with anorexia nervosa have a disturbed self-image and always see themselves as fat and needing further weight loss. The relationship between mother and daughter is often not supportive but instead conflicted. Usually there is high achievement and great concern about grades. Usually there is dissatisfaction with weight and a desire to lose weight.

A depressed client is given sertraline (Zoloft) 50 mg at bedtime. For what drug-related side effects should the nurse monitor the client? Select all that apply. 1 Dry mouth 2 Weight gain 3 Constipation 4 Photosensitivity 5 Projectile vomiting

13 Dry mouth is a common side effect of sertraline (Zoloft) that should be shared with the client because measures can be taken to relieve discomfort; this side effect should subside within 2 to 3 weeks after therapy begins. Constipation is a common side effect of sertraline; an increase in fluids and bulk in the diet may minimize this effect. Weight loss, not gain, may occur because of the side effects of anorexia, dry mouth, indigestion, and nausea. Photosensitivity is not a side effect of this medication. Although nausea and vomiting may occur, the vomiting is not projectile vomiting

A health care provider prescribes carbamazepine (Tegretol) for a client. The nurse teaches the client about effects of the drug that should be reported to the health care provider. Which effects identified by the client as cause to call the provider indicate an understanding of the teaching? Select all that apply. 1 Unusual bleeding or bruising 2 Dizziness or drowsiness 3 Nausea or vomiting 4 Breast enlargement or sexual dysfunction 5 Sensitivity to bright light or sun

13 Nausea and vomiting may be side effects, or they may be signs of toxicity. The client should be evaluated by the health care provider. Carbamazepine (Tegretol) can cause severe bone marrow depression; the client should have weekly complete blood counts for the first 4 weeks of therapy and every 3 to 6 months thereafter. Dizziness and drowsiness are common side effects of carbamazepine that do not require health care provider notification. The client should be cautioned not to engage in hazardous activities such as driving a car. Sensitivity to bright light or sun is not a side effect of carbamazepine. Neither breast enlargement nor sexual dysfunction is associated with carbamazepine.

When a recently hospitalized client has a tentative diagnosis of opioid addiction, the nurse should assess the client for signs and symptoms related to opioid withdrawal. List them in the order that they will occur as the client progresses through withdrawal. 1. Runny nose 2. Severe bone pain 3. Flulike syndromes 4. Return of appetite

1324 When opioids, which are central nervous system depressants, are withdrawn initially, the client will experience a runny nose (rhinorrhea), tearing (lacrimation), diaphoresis, yawning, and irritability. As withdrawal progresses, rebound hyperexcitability precipitates muscle twitching, restlessness, hypertension, tachycardia, temperature irregularities, tremors, and loss of appetite. Finally flulike symptoms, insomnia, and yawning occur. Once withdrawal is complete the appetite returns, vital signs become stable, and other withdrawal signs and symptoms subside and eventually disappear.

A depressed client is receiving paroxetine (Paxil). The nurse monitors this client for the side effects associated with this drug. Select all that apply. 1 Sexual dysfunction 2 Depressed respiration 3 Insomnia and restlessness 4 Hypertension or hypotension 5 Irregular menses or secondary amenorrhea

134 Genitourinary side effects of paroxetine (Paxil) include ejaculatory disorders, male genital disorders, and urinary frequency. Depressed respiration is associated with opioids that depress the central nervous system (CNS). CNS side effects of paroxetine include insomnia, restlessness, dizziness, tremors, nervousness, and headache. Cardiovascular side effects of paroxetine include hypertension, orthostatic hypotension, palpitations, and vasodilation. Irregular menses and secondary amenorrhea are associated with tiagabine hydrochloride (Gabitril), an antiepileptic used for bipolar disorders.

When intimate partner violence (IPV) is suspected, the nurse plays an important role as an advocate for the victim. The advocate role includes several important components. Select all that apply. 1 Planning for future safety 2 Normalizing victimization 3 Validating the experiences 4 Promoting access to community services

134 Planning for the client's future safety needs, validating the client's experiences by letting the victim know that he or she is not alone, and promoting access to community services are all important roles of the nurse advocate. An advocate would not normalize the victimization by seeing the abuse as normal in the victim's relationship and failing to respond to the disclosure of the abuse.

What clinical findings may be expected when a nurse assesses an individual with an anxiety disorder? Select all that apply. 1 Worrying about a variety of issues 2 Acting out with antisocial behavior 3 Converting the anxiety into a physical symptom 4 Displacing the anxiety onto a less threatening object 5 Demonstrating behavior common to an earlier stage of development

1345Excessive anxiety and worry about a number of events, topics, or activities for a 6-month duration are the hallmark of generalized anxiety disorder. Converting anxiety into a physical symptom is an example of a conversion disorder, which eases anxiety. Displacing the anxiety onto a less threatening object, which eases anxiety, is typical of a phobic disorder. Regression is an attempt during periods of stress to return to behavior that has been satisfying and is appropriate at an earlier stage of development. Acting out anxiety with antisocial behavior is most commonly found in individuals with personality rather than anxiety disorders.

A nurse is working with an adolescent client with conduct disorder. Which strategies should the nurse implement while working on the goal of increasing the client's ability to meet personal needs without manipulating others? Select all that apply. 1 Provide physical outlets for aggressive feelings. 2 Discuss how others can precipitate anxiety. 3 Establish a contract regarding manipulative behavior. 4 Develop activities that provide opportunities for success. 5 Encourage the client to verbalize negative feelings to others.

134Channeling energy to healthy physical activities can decrease violent behavior. A behavioral contract is used to reinforce problem solving and encourage the use of social skills. Successful experiences improve the client's self-esteem and should decrease the manipulative behavior. Clients with conduct disorders tend to generate stress for others, not the other way around. Verbalization of negative feelings to others can often escalate and result in antisocial or acting out behavior.

During a home visit to an older adult, the nurse observes a change in behavior and suspects delirium. The nurse assesses the client for one of several conditions that may have precipitated the delirium. Select all that apply. 1 Infection 2 Dementia 3 Dehydration 4 Urine retention 5 Restricted mobility

134Infections, especially urinary tract infections in older clients, may cause delirium because they may become systemic. A memory aid for recalling the causes of delirium is DELIRIUMS: Drugs, Emotional factors, Low arterial oxygen level, Infections, Retention of urine or feces, Ictal or postictal state, Undernutrition, Metabolic conditions, and Subdural hematoma. Dehydration and fluid and electrolyte imbalances may lead to delirium because of the decrease in fluid and change in concentrations of electrolytes in the brain. Retention of urine may progress to a urinary tract infection that becomes systemic, which can cause delirium. Dementia is a chronic, irreversible cause of mental status changes. It must be differentiated from delirium, which is treatable. Restricted mobility is not related to delirium.

An adult who has been in a gay relationship for 3 years arrives at the emergency department in a state of near-panic. The client says, "My partner just left me. I'm a wreck." What should the nurse do to help the client cope with this loss? Select all that apply. 1 Identify the client's support systems. 2 Explore the client's psychotic thoughts 3 Reinforce the client's current self-image. 4 Encourage the client to talk about the situation. 5 Suggest that the client explore personal sexual attitudes.

14 A client in crisis needs to rely on available sources of support for assistance; therefore it is vital for the nurse to identify the client's support system. Talking about the situation helps the individual put the crisis in perspective. Nothing in the history indicates that the client is having psychotic thoughts. Nor is there information to indicate that the client has issues with self-image. Suggesting that the client explore personal sexual attitudes will not help the client cope with the loss and may add to the client's anxiety.

An older client has been prescribed an atypical antipsychotic medication. Which nursing interventions demonstrate that the nurse has determined the client's risk for injury? Select all that apply. 1 Monitoring the pulse for an irregular rhythm 2 Sitting with the client during meals to encourage eating 3 Offering a favorite beverage between meals to maintain hydration 4 Assessing the temperature to determine the possibility of an infection 5 Teaching the client about the importance of taking an anticholinergic medication

14 Older clients prescribed atypical antipsychotic medications are at increased risk for death as a result of cardiovascular dysfunction and infection and should be monitored closely for such situations. This client is at risk for death related to complications of atypical antipsychotic medication therapy, but the risk is not related to poor nutrition, dehydration, or any condition that could be managed with anticholinergic therapy.

A client with a history of chronic alcoholism was admitted to a surgical unit after surgery to repair a severely fractured right ankle. The nurse is concerned that the client is experiencing manifestations of acute alcohol withdrawal when certain documentation and assessment data from the last 6 hours seem to indicate this problem. Select all that apply. 1 Tremors in both hands make it difficult for the client to hold a cup. 2 The client's systolic blood pressure has dropped 6 points over last 6 hours. 3 The client was observed falling asleep while talking on the telephone to family. 4 The client's bed linens and pajamas had to be changed during the night as a result of increased diaphoresis. 5 The usually cooperative client becomes verbally abusive when asked to lower the volume of the television.

145 Agitation is a psychosocial characteristic of alcohol withdrawal. Diaphoresis and tremors are physical characteristics of alcohol withdrawal. Systolic blood pressure would rise rather than fall if the client were experiencing alcohol withdrawal. Insomnia, rather than drowsiness, is a physical characteristic of alcohol withdrawal.

People who are involved in a bioterrorism attack exhibit immediate reactions to the traumatic event. Which responses can a nurse expect in survivors during the period immediately following a traumatic event? Select all that apply. 1 Denial 2 Guilt 3 Altruism 4 Confusion 5 Helplessness

145 Shock and disbelief are the initial responses to a traumatic experience; a situational crisis usually is unexpected, and its impact causes disequilibrium. Disequilibrium results in confusion, disorganization, and difficulty making decisions. When a person is unable to cope, helplessness and regression often emerge; a crisis occurs when there is a painful, frightening event that is so overwhelming an individual's usual coping mechanisms are inadequate. Feelings of guilt may emerge later when the individual moves from focusing on the self to increased interaction with others. Concern for others emerges later, after the individual is able to set aside or resolve his or her own needs.

The nurse and client have entered the working phase of a therapeutic relationship. What can the nurse expect the client to do during this phase? Select all that apply. 1 Initiate topics of discussion. 2 Focus the conversation on the nurse. 3 Repress emotionally charged material. 4 Accept limits on unacceptable behavior. 5 Express emotions related to transference.

145 This phase is focused on developing the client's problem-solving skills while addressing the areas in the client's life that are causing problems. The nurse helps clients identify these topics for discussion. Focusing the conversation on the nurse occurs during the orientation phase, before trust is established. Repressing emotionally charged material occurs during the orientation phase, before trust is established. Resistant behaviors usually are overcome by the working phase. During the working phase of a therapeutic relationship trust is established on the basis of mutual respect. Once trust is established the client will feel comfortable enough to express feelings; feelings of transference and countertransference usually awaken during the working phase of a therapeutic relationship.

A nurse is assigned to care for a group of clients who have been found to have depression. Which clinical manifestations does the nurse anticipate? Select all that apply. 1 Neglect of personal hygiene 2 Labiality of affect 3 Specific food cravings 4 "I don't know" answers to questions 5 Apathetic response to the environment

145Clients with depression are uninterested in their appearance because of low self-esteem. "I don't know" answers to questions type response requires little thought or decision-making, typical of depression. These clients' sense of futility leads to a lack of response to the environment. With depression there is little or no emotional involvement and therefore little alteration in affect. Clients with depression are uninterested in food of any kind.

When determining whether a client has anorexia nervosa or bulimia nervosa, the nurse should identify those characteristics that relate only to anorexia nervosa. Select all that apply. 1 Cachexia 2 Binge eating 3 Constipation 4 Decreased blood pressure 5 Delayed psychosexual development

15 A state of malnutrition with muscle wasting, weakness, and emaciation (cachexia) occurs with anorexia nervosa; clients usually are 15% to 30% below ideal body weight. Many clients with anorexia nervosa exhibit psychological symptoms, including a lack of age-appropriate interest in sex and relationships. Recurrent episodes of the rapid consumption of a large amount of food in a discrete period (binge eating) are associated with bulimia nervosa. Constipation can occur with both anorexia nervosa and bulimia nervosa, usually because of a lack of adequate fluids and intestinally stimulating foods. Hypotension can occur with both anorexia nervosa and bulimia nervosa, usually because of dehydration.

A client tells a nurse, "I have been having trouble sleeping and feel wide awake as soon as I get into bed." Which strategies should the nurse teach the client that will promote sleep? Select all that apply. 1 Leaving the bedroom shen he is unable to sleep 2 Eating a heavy snack near bedtime 3 Reading in bed before shutting out the light 4 Drinking a cup of warm tea with milk at bedtime 5 Exercising in the afternoon rather than in the evening 6 Counting backward from 100 to 0 when his mind is racing

156 Lying in bed when one is unable to sleep increases frustration and anxiety and further impedes sleep; other activities, such as reading or watching television, should not be conducted in bed. Exercise during the day expends energy and promotes sleep at night; exercise too close to bedtime is stimulating and may interfere with sleep. Counting backward requires minimal concentration but is enough to interfere with thoughts that distract a person from falling asleep. A heavy meal exerts pressure against the diaphragm that may be uncomfortable, and the body is expending energy to digest the food; a light, not heavy, snack is preferred before bedtime. The bed should be used exclusively for sleep so the client's body expects sleep when the client gets into bed. Although milk may promote sleep, tea contains caffeine, which is a stimulant that should be avoided after midafternoon; otherwise, it may interfere with sleep.

A nurse who works in a mental health facility determines that the priority nursing intervention for a newly admitted client with bulimia nervosa is to: 1 Check on the client continually. 2 Observe the client during meals. 3 Teach the client to measure intake and output. 4 Involve the client in developing a daily meal plan.

1Bulimic clients often hide food or force vomiting; therefore they must be carefully observed. Observing the client during meals is insufficient because these clients may induce vomiting after eating. Fluid and electrolyte balance can become a problem for these clients and monitoring is required, but at this time it is the responsibility of the nurse, not the client, to measure intake and output. These clients will not become involved in planning meals; this is a long-term goal.

A client who has a diagnosis of paranoid schizophrenia and has been violent in the past is admitted to the psychiatric unit. What should the nurse do before conducting an admission interview? 1 Enter the room with another staff member while remaining between the client and the door. 2 Have two other staff members present when talking with the client. 3 Alert the assault response team about the client's history. 4 Move to the client's side and sit down.

1Making sure to stay between the client and the door provides safety for the nurse and the other staff member because it will enable them to make a rapid exit. Moving to the client and sitting down invades the client's territory and may precipitate an aggressive client response. Alerting the assault response team is premature; the team is alerted when a client is out of control, harming self or others, and cannot be managed by the staff on the unit. Having two other staff members present may be viewed by the client as confrontational and may precipitate an aggressive response.

A client receiving risperidone (Risperdal) is going on an all-day fishing outing with family members. It is important that the nurse: 1 Encourage the client to use sunscreen. 2 Caution the client to avoid excessive activity. 3 Advise the client to bring an additional dose of medication to take after lunch. 4 Have the client take a blood pressure reading before leaving for the fishing outing.

1Risperidone (Risperdal) causes photosensitivity, which can be controlled with the use of sunscreens and protective clothing. Cautioning the client to avoid excessive activity is not a necessary precaution with this atypical antipsychotic drug; the client should be allowed to participate fully. The medication should be administered as prescribed; additional doses should not be administered. Participating in an outing should not affect the client's blood pressure.

A depressed client cries when the family does not visit. What is the most therapeutic response by the nurse? 1 "Your family didn't visit, and now you're feeling rejected." 2 "It's difficult to realize that no one cares about you." 3 "It's terrible to have such negative thoughts about yourself." 4 "Your family members work—that's why they don't visit you."

1The statement "Your family didn't visit, and now you're feeling rejected" accurately reflects the client's emotions and may encourage exploration of feelings. The nurse does not know that no one cares about the client, and the statement may increase the client's unhappiness. The client is upset about the lack of visitors; discussing negative thoughts about self changes the subject. The defensive statement "Your family members work—that's why they don't visit you" may worsen the client's self-derogatory feelings.

The nurse determines that to help a couple work through their feelings about the husband's terminal illness, it is important to: 1 Refer the husband to the psychotherapist for assistance in coping with his anger. 2 Assist the couple to express their feelings about his terminal illness to each other. 3 Encourage the wife to verbalize her feelings to a therapist during a therapy session. 4 Place the couple in a couples' therapy group that addresses the terminal illness of one partner.

2

A nurse is caring for a client who is experiencing auditory hallucinations. What is the most therapeutic response by the nurse? 1 "Those voices you hear aren't real." 2 "I don't hear the voices you're hearing." 3 "Try to focus your attention on other things." 4 "You won't hear the voices when you get better."

2 "I don't hear the voices you're hearing" points out reality without being demeaning or arguing with the client. The voices are real to the client, and stating otherwise will not be believed. Trying to focus the client's attention on other things is probably impossible. The client will be unable to focus on the future when attempting to cope with the frightening experience of hearing voices in the present; also, it may be false reassurance.

A nurse develops a relationship with a client who has bipolar disorder with episodes of mania. The nurse concludes that their therapeutic interaction has entered the working stage when the client: 1 Informs the nurse that other family members are bipolar 2 Explores the effect of bipolar behavior on the family 3 Identifies goals for the client-nurse interaction 4 Expresses ambivalence about meeting with the nurse

2 Acknowledging and exploring issues is part of the working phase of a therapeutic relationship. Formulating the purpose or goals of the therapeutic relationship is part of the orientation or introductory phase. The orientation or introductory phase of a therapeutic relationship involves tension and anxiety within an uncertain situation. Ambivalence is not an uncommon feeling. Having the client share the family history is a part of the orientation or introductory phase of a therapeutic relationship.

A nurse understands that autism is a form of a pervasive developmental disorder (PDD). Which factor unique to autism differentiates it from other forms of PDD? 1 Less severe linguistic handicaps 2 Early onset, before 36 months of age 3 The only form that does not include seizures 4 The only form that does not include cognitive impairment

2 Autism impairs bonding and communication and therefore becomes apparent early in life. Autism involves both delayed and deviant linguistic problems. About 25% of children with autism have a seizure disorder. Autism may, and often does, include cognitive impairment.

A pregnant client with a history of delusions, hallucinations, and suspiciousness tells the nurse she is fearful about the upcoming birth and the health of her baby. What is the best initial approach by the nurse? 1 Reassuring the client that she will have help with the birth 2 Commending the client on her ability to express her concerns 3 Sharing with the client the staff's concerns about how she will handle the infant 4 Providing the client with a detailed explanation of what occurs during the birthing process

2 Because suspicious clients lack trust and have difficulty sharing feelings, this healthy behavior should be identified as the first step in developing a trusting relationship. The client's feelings are dismissed when reassuring blanket statements are given; this responds to only part of the client's concerns. Focusing on the staff's concerns ignores the client's needs; the staff's attitude may decrease self-esteem. A detailed description at this time may increase the client's fears.

A client has been in an acute care psychiatric unit for 3 days and is receiving haloperidol (Haldol) tablets orally to reduce agitation and preoccupation with auditory hallucinations. There has been no decrease in the client's agitation or preoccupation with auditory hallucinations since the medication was started. What should the nurse's priority intervention be? 1 Asking the health care provider to change the medication 2 Making certain that the client is swallowing the medication 3 Concluding that a therapeutic level of the drug has not been achieved 4 Securing a prescription for as-needed sedation until the client calms down

2 Because the medication is being taken orally, the client may be pocketing the tablet in the buccal cavity and discarding it later; the nurse must check to ensure that the administered medication is swallowed. Asking the health care provider to change the medication may not be a response failure. If the client is swallowing the medication, this may be necessary; the nurse first should ensure that the medication is swallowed. This medication reaches a peak of action in 3 to 5 hours.

A nurse approaches a depressed client who has just been admitted to the psychiatric unit and says, "Hello! I'm Andrea, your nurse. I'll introduce you and help you settle in with the others here. We'll also talk about anything that concerns you." These statements establish the nurse-client relationship by: 1 Providing a theme 2 Defining boundaries 3 Identifying problems 4 Initiating the working phase

2 Boundary development and maintenance, safety, and the development of trust are the three basic concepts of an initial therapeutic relationship. Boundaries define and separate the self from the client and indicate one's responsibilities in relation to the other individual. Themes are recurring patterns of interaction with others throughout life. The identification and clarification of problems, the client's position and understanding of the problems, and the nurse's understanding of the problems take place in the working phase of the therapeutic relationship. After boundaries and a sense of safety are developed, trust must developed; only then can the working phase begin. However, there is no clear delineation between the end of the orientation phase and the beginning of the working phase.

A female client with a diagnosis of alcohol abuse appears disheveled and disorganized. How can the nurse best gain the client's involvement in personal hygienic care? 1 Devising a schedule with her and making certain that she adheres to it 2 Assisting her in bathing and dressing by giving her clear, simple directions 3 Bathing and dressing her each morning until she is willing to do it for herself 4 Giving her a schedule that requires her to bathe and dress herself each morning

2 Clear directions provide the disorganized client with the necessary structure to encourage participation and support a positive self-image. Making a schedule with her and ensuring that the client adheres to it will increase the client's anxiety and foster withdrawal; also, it may decrease the client's level of function. Bathing and dressing the client will increase dependency and add to the client's self-doubt. Giving the client a schedule and ensuring that she sticks to it will increase the client's anxiety and foster withdrawal; also, it may decrease the client's level of function.

An extremely anxious client enters a crisis center and asks a nurse for help. Which initial response best reflects the nurse's role in crisis intervention? 1 "Tell me what you've done to help yourself." 2 "I'll be here for you to help you figure things out." 3 "I understand that in the past you've had problems." 4 "Tell me about the things that are bothering you the most."

2 Clients in crisis need assistance with coping; the nurse must be involved with problem solving. Clients in crisis initially need to trust the nurse. Telling the client that the they are there to help develops trust. Although asking what the client has done to help himself, telling the client a positive interview statement, this does not focus on the nurse's involvement with problem solving.

When working with a client who is in an alcohol detoxification program, it is most important for the nurse to: 1 Support the client's need for nurture. 2 Address the client's holistic needs. 3 Discuss with the client the negative effects of alcohol. 4 Promote the client's compliance with the program through gentle prodding.

2 Clients who abuse alcohol characteristically have multiple nursing care needs, among them physiological, psychological, social and occupational. Although nurture is important, this client must learn self-reliance. Discussing with the client the negative effects of alcohol is probably an old story to this client and will have a minimal positive effect. Promoting the client's compliance with the program through gentle prodding will not provide an atmosphere that can help the client withstand the stress of the detoxification program.

o begin to establish a therapeutic relationship with a withdrawn, reclusive client, the nurse must: 1 Protect the client from self-destructive tendencies. 2 Help the client keep anxiety to a minimum. 3 Ascertain what topics are of most interest to the client. 4 Obtain a complete history from the family before talking with the client.

2 Creating an environment that eases anxiety promotes a feeling of security; as this continues, a sense of trust in this individual is established. The client is not exhibiting self-destructive tendencies at this time. Ascertaining what topics are of most interest to the client is less important in the beginning phase of a relationship. Obtaining a complete history from the family before talking with the client is not important in establishing a therapeutic relationship.

What should a nurse include in the plan of care for a client with vascular dementia? 1 A reeducation program 2 Details of supportive care interventions 3 An introduction of new leisure-time activities 4 Plans for involvement in group therapy sessions

2 Damaged brain cells do not regenerate. Care is therefore directed toward preventing further damage and providing protection and support. The deterioration of the brain cells makes plans for a reeducation program unrealistic. A client with this disorder may not be able to grasp, understand, or enjoy new leisure activities. It is beyond the scope of the client's ability to function in a group therapy session.

When caring for a client with bulimia nervosa, the nurse remembers that bulimia nervosa follows a cyclical pattern. The nurse identifies the first pattern in this cycle as: 1 Hunger resulting from food deprivation and stress 2 Dieting in an attempt to maintain control of one's life 3 Binge eating to numb physical and emotional discomforts 4 Purging in another attempt to regain control and alleviate guilt

2 Dieting may be one area of control the person has in her life, and she elects to exercise control over it. The body does experience hunger, and binge eating serves as emotional comfort when the person ingests large amounts of calories. Purging is the final phase in this cycle; individuals are unaware often that purging rids fewer than 50% of the calories ingested.

A health care provider prescribes haloperidol (Haldol) for a client. What should the nurse teach the client to avoid while taking this medication? 1 Driving at night 2 Staying in the sun 3 Ingesting aged cheeses 4 Taking medications containing aspirin

2 Haloperidol (Haldol) causes photosensitivity. Severe sunburn may occur on exposure to the sun. There is no known side effect that affects night driving. Aged cheeses would be prohibited if the client were taking a monoamine oxidase inhibitor; people taking psychotropic medications should avoid alcohol. Aspirin is not contraindicated.

Two depressed clients are sharing a room. The health team has established a goal of increased socialization for each client. Which action will be most effective in facilitating interaction between these two clients? 1 Taking them to a unit bingo game together 2 Putting a puzzle together with them in their room 3 Exploring their reluctance to engage in conversation 4 Suggesting that they watch television together in their room

2 Helping the two clients work on a puzzle provides an opportunity for interaction. This is a noncompetitive activity that requires both interaction and some degree of cooperation. Taking the two to a bingo game gets them out of their room but does not facilitate interaction Discussing their reluctance to converse will do little to facilitate mutual interaction. Watching television does not foster social interaction.

When having a conversation with a nurse, an older client states, "I've lived a good life. I don't want to die, but I accept it as a part of life." What developmental stage, according to Erikson, has the client completed? 1 Identity 2 Integrity 3 Acceptance 4 Generativity

2 Integrity is the last stage of life, identified by the acceptance of life as lived and the inevitability of death. Identity is a developmental task of adolescence. Acceptance is not a term used by Erikson; it is the final stage of Kübler-Ross' theory of death and dying. Generativity is a developmental task of middle-aged people.

Oral chlordiazepoxide (Librium) 100 mg/ hr is prescribed for a client with a Clinical Institute Withdrawal Assessment (CIWA) score of 25. The client has had 300 mg in 3 hours but is still displaying acute alcohol withdrawal symptoms. What is the next nursing action? 1 Informing the client that the limit of chlordiazepoxide has been reached 2 Administering chlordiazepoxide as indicated by the client's CIWA score 3 Requesting a prescription for another medication to replace the chlordiazepoxide 4 Informing the health care provider that the maximum dose of chlordiazepoxide has been reached

2 Medication of clients in acute withdrawal from alcohol should be based on withdrawal symptoms, not medication dosage. The use of the CIWA for alcohol scale promotes assessment and evaluation of the client experiencing withdrawal. Clients withdrawing from alcohol can tolerate abnormally high doses of chlordiazepoxide (Librium) and should be medicated on the basis of their withdrawal symptoms. There is no reason to switch to another medication; the fact that withdrawal symptoms are still being displayed indicates that the client can tolerate higher doses of chlordiazepoxide. Informing the health care provider that the maximal dose of chlordiazepoxide has been reached is unnecessary because the client, who is still displaying withdrawal symptoms, can tolerate higher doses of Librium.

How can the nurse best minimize psychological stress in an anxious client who has been admitted to the psychiatric unit? 1 Explain in detail the therapies being used. 2 Learn what is of particular importance to the client. 3 Advise the client that the nurse is in charge of the client's situation. 4 Avoid the discussion of any areas that may be emotionally charged.

2 Providing support, understanding, and acceptance of feelings that the client is experiencing is essential for reducing stress. Explaining in detail the therapies being used most likely will have the effect of increasing the client's anxiety. Advising the client that the nurse is in charge of the client's situation is an authoritarian approach. The psychiatric unit provides the client with a safe, accepting environment in which to face problems and discuss emotionally charged areas.

A nurse is admitting a client to the unit. What interaction demonstrates effective therapeutic communication principles? 1 Speaking slowly to convey calm and relaxation 2 Maintaining a distance of at least 3 feet from the client 3 Asking closed-ended questions to help secure desired information 4 Requesting an interpreter if the client's English cannot be understood

2 Respecting personal space is a basic principle of therapeutic communication. A separation of 3 to 6 feet is considered appropriate and comfortable for nurse-client conversations. Although communication is facilitated by a calm, relaxed environment, it will not have an impact on the therapeutic nature of a conversation between the nurse and the client. Sometimes a closed-ended question may be appropriate, but this technique usually serves as a barrier to effective therapeutic communication. Although calling for an interpreter is an appropriate intervention, it will not have an impact on the therapeutic nature of a conversation between the nurse and the client.

During the admission process, a client with symptoms of manic behavior has pressured speech punctuated with profanity. What is the most therapeutic approach for the nurse to use to manage this client's behavior? 1 Explaining in detail the type of behavior allowed in the facility 2 Stating that the use of profanity should stop because it is inappropriate 3 Interrupting the interview until the client refrains from using profanity 4 Encourage the client to keep talking while using a nonjudgmental attitude

2 Setting limits on acting-out behavior may prevent an escalation of anger that may result in harm to the client or others. Detailed explanations are not helpful because the client's easy distractibility interferes with understanding. Interrupting the interview without setting limits on the behavior will be ineffective. Clients with pressured speech do not need encouragement to talk. The nurse may be nonjudgmental but must also set limits on inappropriate language and behavior to provide needed structure and feedback.

A nurse is performing discharge teaching for a client who has been receiving disulfiram (Antabuse). What statement indicates to the nurse that the client understands the teaching concerning disulfuram? 1 "I can never take this medication at the same time as an antibiotic." 2 "I have to be careful to check over-the-counter medications." 3 "I won't be able to eat aged cheeses while I'm taking this medication." 4 "I should wait at least 8 hours after taking this pill before drinking alcohol."

2 Some over-the-counter medications contain alcohol and may trigger a reaction. Disulfiram (Antabuse) and antibiotics generally can be administered concurrently. The response "I will not be able to eat aged cheeses while taking this medication" is appropriate for clients receiving monoamine oxidase inhibitors (MAOIs). Disulfiram is aversion therapy for clients who abuse alcohol. Eight hours after the medication is taken, adverse effects can still occur. These include severe nausea, vomiting, hypotension, headache, tachycardia, tachypnea, flushed face, and bloodshot eyes.

A withdrawn client refuses to get out of bed and becomes upset when asked to do so. What nursing action is most therapeutic? 1 Requiring the client to get out of bed 2 Staying with the client until the client calms down 3 Giving the client the PRN antipsychotic that is prescribed 4 Leaving the client alone in bed for as long as the client wishes

2 Staying with the client until the client calms down provides support and security without rejecting the client or placing value judgments on the behavior. Eventually limits will have to be set in giving care, but staying with the client and showing acceptance are immediate nursing actions. Although giving the client the PRN antipsychotic will calm the client, it does not address the problem. Leaving the client alone in bed for as long as the client wishes ignores the problem; isolation implies punishment.

A nurse uses the CAGE screening test for alcoholism to determine an individual's potential for a drinking problem. What is one of the four questions included on this test? 1 "Do you feel that you are a normal drinker?" 2 "Have you ever felt bad or guilty about your drinking?" 3 "Are you always able to stop drinking when you want to?" 4 "How often did you have a drink containing alcohol in the past year?"

2 The CAGE screening test for alcoholism contains four questions, corresponding to the letters CAGE: Have you ever felt you ought to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning (as an "Eye-opener") to steady your nerves or get rid of a hangover? "How often did you have a drink containing alcohol in the past year?" is one of the 10 questions on the Alcohol Use Disorders Identification Test (AUDIT). "Do you feel that you are a normal drinker" and "Are you always able to stop drinking when you want to" are two of the 26 questions on the Michigan Alcohol Screening Test (MAST).

A client with schizophrenia is admitted to a psychiatric unit. The client is talking while walking in the hall, is unkempt, and obviously has not washed in several days. What should the nurse say when trying to help this client shower? 1 "Would you like a shower?" 2 "I'll help you take your shower now." 3 "When do you want your shower, now or later?" 4 "You'll feel so much better if you have a shower."

2 The client is displaying a self-care deficit; stating the intention of helping the client shower is direct, does not require the client to make a decision, provides help, and meets the client's physiological and psychological needs. The client may or may not be capable of making a decision; if the client says no, the nurse will be confronted with a dilemma: meeting the client's physiological needs will contradict the client's wish not to bathe. The client may not be able to tell the nurse when he wants to shower because he may be incapable of making a decision. "You'll feel so much better if you have a shower" may be false reassurance; the client may not be able to process cause and effect.

A client in the outpatient clinic is denying that he is addicted to alcohol. He tells the nurse that he is not an alcoholic and that it is his nagging wife who causes him to drink. What is the most therapeutic response by the nurse? 1 "I don't think that your wife is the problem." 2 "Everyone is responsible for his own actions." 3 "Perhaps you should have marriage counseling." 4 "Why do you think that your wife is the cause of your problems?"

2 The comment "Everyone is responsible for his own actions" encourages the client to accept responsibility and does not support denial as a defense mechanism. Although the comment "I don't think that your wife is the problem" may be true, it may also close off communication; with a decrease in communication the nurse cannot be effective in helping break through the denial. Although suggesting marriage counseling may be appropriate, it does not address the issue of denial. The comment "Why do you think that your wife is the cause of your problems?" enables the client to continue to avoid responsibility for his own behavior.

A young adult being treated for substance abuse asks the nurse about methadone. The nurse responds that methadone is useful in the treatment of opioid addiction because it: 1 Is a nonaddictive drug 2 Has an effect of longer duration 3 Does not produce a cumulative effect 4 Carries little risk of psychological dependence

2 The duration of effect of methadone is 12 to 24 hours, compared with other opioids, which have a 3- to 6-hour duration of effect. It is just as addictive but controls the addiction and keeps the client out of the illicit drug market. Methadone does produce a cumulative effect. Physical as well as psychological dependence is possible, just as with other opioids.

A nurse is assessing a young adult for evidence of achievement of the age-related developmental stage set forth in Erikson's developmental theory. What developmental crisis is associated with this age group? 1 Trust versus mistrust 2 Intimacy versus isolation 3 Industry versus inferiority 4 Generativity versus stagnation

2 The major task of young adulthood is centered on human closeness and sexual fulfillment; lack of love results in isolation. The trust-versus-mistrust stage is associated with infancy. The industry-versus-inferiority stage is associated with middle childhood (school age). The generativity-versus-stagnation stage is associated with middle adulthood.

An older adult with a chronic degenerative disease progresses to the stage at which self-care is no longer possible, and admission to a long-term care facility becomes necessary. What is the major developmental conflict for this client, according to Erikson? 1 Intimacy versus isolation 2 Ego integrity versus despair 3 Identity versus role diffusion 4 Generativity versus stagnation

2 The need for acceptance of life as fulfilling and meaningful is the major task of the older adult. Intimacy versus isolation is the task of young adulthood (18 to 25 years); it involves establishment of an intimate relationship and occupation. The task of the adolescent (12 to 20 years) is establishing identity through work and development of relationships and an occupation. Generativity versus stagnation is the task of adulthood (21 to 45 years); it involves establishment of a family and guidance of the next generation.

A young woman who has just lost her first job comes to the mental health clinic very upset and says, "I just start crying without any reason and without any warning." How should the nurse respond initially? 1 "Are you having any other problems at this time?" 2 "Crying unexpectedly can be very upsetting." 3 "Do you know what makes you cry?" 4 "Most of us need to cry from time to time."

2 The response "Crying unexpectedly can be very upsetting" identifies the client's feelings. Asking, "Do you know what makes you cry?" is an unrealistic question; the cause of anxiety may not be known. "Most of us need to cry from time to time" moves the focus away from the client. "Are you having any other problems at this time?" disregards the client's comment; it is a direct question that may impede communication.

As a client addicted to cocaine withdraws from the drug, the nurse should expect to observe behavior related to: 1 Insomnia 2 Depression 3 Disinhibition 4 Hyperactivity

2 There is no set of symptoms associated with cocaine withdrawal, only the depression that follows the high caused by the drug. Insomnia is more commonly associated with withdrawal from central nervous system depressants. Disinhibition is commonly associated with alcohol intoxication. Hyperactivity is more commonly associated with withdrawal from opioids or antianxiety drugs.

A client has been taking prescribed risperidone (Risperdal) 3 mg twice a day for the past 8 days. A friend brings the client to the outpatient clinic. The client reports tremors, shortness of breath, a fever, and sweating. What should the nurse do? 1 Call 911 and have the client transported to the nearest psychiatric unit. 2 Take the client's vital signs and arrange for immediate transfer to a hospital. 3 Check the number of risperidone tablets left in the prescription bottle to see whether there was an overdose. 4 Request a prescription for intramuscular benztropine (Cogentin) 2 mg stat and assess the client in 10 to 15 minutes for symptom relief.

2 These clinical manifestations signal the presence of neuroleptic malignant syndrome; the cardinal sign of this condition is a high body temperature. Therefore the nurse first should document the hyperthermia and then arrange for immediate hospitalization. Unless the client is experiencing impaired ventilation, it is important to complete a focused assessment before transfer. The care needed can be provided in an emergency department or medical unit, not a psychiatric unit. Neuroleptic malignant syndrome may occur without an overdose; this syndrome can occur when a high-potency antipsychotic drug is prescribed, with typical onset within 3 to 9 days after initiation of the medication. Benztropine (Cogentin) will have little or no effect on neuroleptic malignant syndrome.

A nurse is administering hydroxyzine (Vistaril) to a client. For which common side effects of this drug should the nurse monitor the client? 1 Ataxia and confusion 2 Drowsiness and dry mouth 3 Vertigo and impaired vision 4 Slurred speech and headache

2 This drug suppresses activity in key regions of the subcortical area of the central nervous system; it also has antihistaminic and anticholinergic effects. Ataxia and confusion, vertigo and impaired vision, and slurred speech and headache are not associated with hydroxyzine.

A nurse is caring for a newly admitted, extremely depressed client. The most appropriate initial goal for the client is: 1 Setting realistic life goals 2 Developing trust in others 3 Expressing hostile feelings 4 Getting involved in activities

2 Trust must develop before the nurse-client relationship can move toward the working phase of the relationship. There is nothing to indicate that the client has unrealistic goals. Expressing hostile feelings is a later goal; depressed clients find it difficult to express anger and hostility. Getting involved in activities is a later goal; depressed clients initially do not have the emotional or physical energy to get involved in activities.

A client who is addicted to opioids undergoes emergency surgery. During the postoperative period the health care provider decreases the previously prescribed methadone dosage. For what clinical manifestations should the nurse monitor the client? 1 Constipation and lack of interest in surroundings 2 Agitation and attempts to escape from the hospital 3 Skin dryness and scratching under the incision dressing 4 Lethargy and refusal to participate in therapeutic exercises

2 When the methadone dosage is reduced, a craving for opioids may occur, anxiety will increase, and the client will become agitated and may try to leave the hospital to secure drugs. Lethargy and refusal to participate in therapeutic exercises may occur with methadone overdose. Constipation and lack of interest in surroundings and skin dryness and itching under the incision dressing are not related to methadone dosage reduction.

A client in the psychiatric hospital is attempting to communicate by stating, "Sky, flower, angry, green, opposite, blanket." The nurse recognizes this type of communication as: 1 Echolalia 2 Word salad 3 Confabulation 4 Flight of ideas

2 Word salad is an incoherent mixture of words. Echolalia is a pathologic repetition of another's words or phrases. Confabulation is the unconscious filling in of memory gaps with imagined or untrue experiences. Flight of ideas is a speech pattern of rapid transition from topic to topic. The client's statement is too limited to be considered flight of ideas.

A small fire has been set in the dayroom garbage can by a client who is currently demonstrating manic behavior. Place the following nursing interventions in the appropriate order to best ensure client and milieu safety. 1. Activate the unit's fire alarm system. 2. Move all clients to a safe, controlled area. 3. Administer appropriate medications as prescribed if indicated. 4. Place the manic client in a quiet environment with low stimulation.

2143 Ensuring the safety of the milieu is the priority. The fire alarm is activated immediately after all clients and staff have been removed from the area of the fire. The next intervention is providing the manic client with a quiet low-stimulation environment. If the nursing assessment indicates a need for medication to manage the client's behavior, it should then be administered.

A client who is a polysubstance abuser has been ordered by the court to seek drug and alcohol counseling. When working with the client, the nurse identifies several treatment goals. List in priority order the outcome criteria for this client. 1. Discusses effect of drug use on self and others 2. Verbalizes that a substance abuse problem exists 3. Explores the use of substances and problematic behaviors 4. Expresses negative feelings about the current life situation

2143 The client must first acknowledge that a substance abuse problem exists and creates chaos in his life. The client can then discuss the numerous ways in which drug use has changed and controlled his life. Assistance from the nurse may be required at this time for the client to express and process negative feelings. Finally the client will require assistance in establishing the relationship between substance use and his current problems.

When helping a client cope with a crisis, the health care provider should follow the principles of intervention. Place the following interventions in order of their priority. 1. Stabilizing the client 2. Intervening immediately 3. Encouraging self-reliance 4. Facilitating understanding of the event 5. Using the available resources

21453 The sooner a client who has experienced a crisis receives professional intervention, the sooner the individual can be helped to cope effectively. The client must then be stabilized to ensure that order has been reestablished in regard to their physical and emotional status. Understanding the event helps the individual move from shock and disbelief to the next stage of coping. Using resources helps the individual move toward resolution of the crisis. Eventually the client can move toward self-reliance.

When a client enters the emergency department in a psychiatric emergency, the nurse should perform an assessment in an organized manner. Place the following interventions in their order of priority, beginning with number 1 as the highest priority. 1. Obtain the chief complaint. 2. Collect identifying information. 3. Explore the previous psychosocial history. 4. Document collected information on the clinical record. 5. Identify presenting clinical findings.

21534 A brief collection of demographic information, particularly the client's name, should be part of the beginning of the nurse-client relationship. The client's perspective of the situation should be obtained after demographic information is collected. While talking with the client, the nurse assesses the client's presenting physical, emotional, and mental status. A psychosocial history is the least important of the assessments. Documentation may be done last. Continuous documentation may interfere with the nurse-client relationship.

A male client with the diagnosis of gender identity disorder has been dressing and functioning in society as a woman for 2 years and has decided to have sex-reassignment surgery. He tells a nurse that all his life he has considered himself female. Place the following nursing interventions in order of priority. 1. Treating the client with respect 2. Investigating one's own feelings about sexuality 3. Accepting the client's decision to have sex-reassignment surgery 4. Exploring ways in which the decision can be shared with significant others 5. Encouraging the client to explore his feelings

21534 Because the self is the most important factor the nurse brings to the nurse-client therapeutic relationship, the nurse must understand personal feelings about issues surrounding this client's situation and needs; this is part of the preorientation phase of a therapeutic relationship. In a therapeutic relationship the client is the focus of care, and the relationship should be based on respect. In an atmosphere of respect, the client is more likely to express feelings. The client considering sex-reassignment surgery should explore all alternatives. However, once the decision is made the nurse should support it. After this important decision is made, the client may need assistance in informing significant others.

Older single men with chronic health problems are at the highest risk of suicide. This is because men have fewer social supports than women do. (Men are less social then women in general.) Less social support at times of stress can increase the risk of suicide. Also, chronic health problems can lead to learned helplessness, which can lead to depression. People who are acutely psychotic as a group are at higher risk for suicide, but they do not have the suicide rate of older single adult men with chronic health problems. An adolescent who was recently sexually abused, although severely traumatized, does not have the risk of suicide of an elderly single man with chronic health problems. Dysfunctional grieving is prolonged grieving that is characterized by greater disability and dysfunctional patterns of behavior. Although people with complicated dysfunctional grieving may be at risk for self-directed violence, they do not have the suicide risk of elderly single men with chronic health problems.

23 It is important that the client have a safe place to go and a plan for getting there. The client needs to know the hotline number if there is an emergency. It is best to memorize the number, because if it is written down the abuser may find it. Any change, especially one in which the abuser becomes angry, may cause the woman to experience more abuse. Although the client will require money to leave the abusive situation, it is best to save money a little at a time rather than try to obtain a loan and alert the abuser of the desire to leave. It is not advisable to tell a family member about the plan to leave because the person may tell the abuser.

While assessing an older adult client before noon the nurse smells alcohol on the man's breath. After noting certain other signs, the nurse suspects that the client is an alcoholic. What are these signs? Select all that apply. 1 Good nutritional habits 2 Excessive mood swings 3 Family conflict 4 Poor hygiene 5 Irritability 6 Maintenance of cognition

2345 Irritability is often seen in alcoholics and is a definite sign to look for. Alcoholics tend to forget to bathe, wash their clothes, or even eat correctly. Many alcoholics have been pushed away by their families because of their drinking and the habits it fosters. Excessive mood swings are a sign of alcoholism. Alcoholics have poor nutritional habits and often skip meals in favor of alcohol. Elders who drink to excess are susceptible to cognitive decline.

A nurse is implementing interventions to assist an aggressive client in deescalating the agitated behavior. Select all that apply. 1 Physical contact with the client to show caring 2 Encouraging the client to express his perceived needs 3 Avoiding verbal struggles in an attempt to demonstrate authority 4 Providing the client with clear options to the unacceptable behavior 5 Referring to the client in an authoritarian manner to demonstrate control of the situation 6 Explaining the expected outcomes if the client is unable to control the unacceptable behavior

2346 Encouraging the client to express his perceived needs provides the client with a sense of being heard and respected. Verbal struggling will likely increase the tension and aggressive behavior of the client. Providing options will allow the client to effectively change behaviors if he is capable of doing so. Explaining outcomes for continued unacceptable behavior allows the client to make a decision to change behaviors if he is capable of doing so. Touching the client will likely be viewed as aggressive and lead to an increase in the client's agitation. It is important to present a calm, firm persona but avoid being authoritarian because this will likely lead to a power struggle.

A nurse teaches dietary guidelines to a client who will be receiving tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor (MAOI). The client compiles a list of foods to avoid. Which foods included on the list indicate that the teaching has been effective? Select all that apply. 1 French fries 2 Pepperoni pizza 3 Bologna sandwich 4 Hamburger on a bun 5 Hash brown potatoes

23Cheese and processed meats contain tyramine, which is contraindicated when MAOIs are taken. Tyramine, a precursor in the synthesis of norepinephrine, taken in the presence of MAOIs can lead to a sharp increase in norepinephrine and a potentially fatal hypertensive crisis. Although bread does not contain tyramine, bologna does; delicatessen meats (e.g., bologna, sausage), meat extracts, and liver are high in tyramine and should be avoided. French-fried potatoes, hamburgers and bread, and hash brown potatoes do not contain tyramine and are not contraindicated when a client is taking an MAOI.

A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? Select all that apply. 1 Dementia 2 Multiple losses 3 Declines in health 4 A milestone birthday 5 An injury requiring hospitalization

23Depression in the older adult is most often associated with the loss of family members and friends (e.g., death, relocation) and declines in mobility, health, and income. A decline in health, particularly when associated with a chronic illness, frequently precipitates depression in older adults. Dementia is a cognitive problem. Research does not correlate the onset of depression with a milestone birthday in older adults. A traumatic injury does not precipitate the onset of depression in the older adult as often as does a chronic illness.

A nurse in the mental health clinic has been working regularly with a client. What client behaviors indicate that trust in the nurse has developed? Select all that apply. 1 Attends a weekly self-help group 2 Demonstrates decreased muscle tension 3 Initiates conversation with others in the waiting room 4 Maintains direct eye contact when talking with the nurse

24 Decreased muscle tension reveals a reduction in stress and anxiety. This indicates increased trust and comfort in the nurse-client relationship. Maintenance of eye contact reflects a connection to the other person. This indicates increased trust and comfort in the nurse-client relationship. Attending a weekly self-help group is unrelated to a therapeutic nurse-client relationship. Initiating conversation with others in the waiting room is unrelated to a therapeutic nurse-client relationship.

A client with chronic depression has a history of suicidal ideations. Place the following nursing assessment questions in the appropriate order to best ensure client safety. 1. What is your plan for killing yourself? 2. Are you thinking about hurting yourself? 3. How would you get what you need to end your life? 4. Have you decided upon a plan to harm yourself?

2413 The initial action is to determine whether the client jntends to commit suicide. The second step is to determine whether the client has made the intention specific by planning a method of suicide. The third step is to determine to what extend the client has decided on the details of the act of suicide. Finally it is necessary to determine whether the client has the means to actually complete the plan.

The registered nurse managing the care of four clients is determining individual priorities. Place the following clients in order of priority, with 1 as the highest priority. 1. A client whose auditory hallucinations are telling her, "They're going to get you." 2. A depressed client who shares with her roommate that she is "very happy today" 3. A cognitively impaired older adult who believes that her dead husband will visit today 4. A manic client who has spent the last 8 hours refusing liquids and pacing around the unit

2413 The priority client is possibly "happy" because she has arrived at the decision to commit suicide; she is potentially at great risk for self-harm (physical need). Constant physical activity and a lack of food place the manic client at risk for fatigue and dehydration (physical needs). Paranoia can result in the hallucinating client's becoming anxious and possibly acting out (emotional need). Though under the misconception that her dead husband will visit, the cognitively impaired client is currently expressing neither a physical nor an emotional need.

A client who was in an automobile accident is admitted to the hospital with multiple injuries. Approximately 14 hours after admission, the client begins to experience signs and symptoms of withdrawal from alcohol. Which signs and symptoms should the nurse connect to alcohol withdrawal? Select all that apply. 1 Fatigue 2 Anxiety 3 Runny nose 4 Diaphoresis 5 Psychomotor agitatio

245 When a person is withdrawing from alcohol, associated autonomic hyperactivity causes an increased heart rate and diaphoresis. The withdrawal of alcohol affects the central nervous system resulting in excited motor activity. Fatigue is associated with withdrawal from caffeine or stimulants. Anxiety is commonly associated with withdrawal from alcohol. A runny nose and tearing of the eyes are associated with withdrawal from opioids.

When a nurse is admitting an older client to the mental health unit, it is important to identify any signs of dementia. What signs and symptoms denote the presence of dementia of the Alzheimer type? Select all that apply. 1 Ambivalence 2 Forgetfulness 3 Flight of ideas 4 Loose associations 5 Expressive aphasia

25 Clients with the diagnosis of schizophrenia or depression are often indecisive and ambivalent. Older clients who have dementia often have short-term memory loss. A client who is experiencing a manic episode of bipolar disorder experiences flight of ideas. Loose associations between thoughts are related to schizophrenia, not dementia. Clients in whom dementia is developing often have difficulty expressing themselves (expressive aphasia) or understanding the spoken word (receptive aphasia).

A client with a history of aggressive, violent behavior is admitted to the psychiatric unit involuntarily. The nurse, who understands the need to use deescalation approaches during the preassaultive stage of the violence cycle, monitors the client's behavior closely for progression of signs of impending violence. List these client assessments in order of escalating aggression, from the lowest risk to the highest. 1. Pacing in the hall 2. Increasing tension in facial expression 3. Engaging in verbal abuse toward the nurse 4. Pushing another client while waiting in line to the dining room 5. Having difficulty waiting to take turns during a group project

25134 Increasing tension in facial expression indicates increasing anxiety, but the client is still maintaining self-control. Impulsivity, as demonstrated by the inability to take turns with others, indicates that the client is having some difficulty setting limits on his or her own behavior. When anxiety escalates to the point of hyperactivity and pacing behaviors, the client is attempting to cope with the anxiety and to discharge physical and psychic energy. Engaging in verbal abuse may precipitate physical abuse and is a sign that the client is not able to maintain self-control. The laying on of the hands in an offensive manner is a physical act of aggression.

A young woman is brought to the emergency department by friends after being sexually assaulted. The client has a small but deep laceration on her chin, as well as contusions on her arms and legs. The client appears withdrawn but calm. Place the following nursing interventions in the appropriate order to best address the client's immediate needs. 1. Provide care for her laceration and contusions. 2. Talk to her in a calm, nonjudgmental manner. 3. Encourage her to express her feelings concerning the assault. 4. Advise her of the potential related health risks and the treatments that are available. 5. Provide her with clear, concise explanations of care that will be provided.

25134 The establishment of a trusting, mutually respectful nurse-client relationship is the initial focus in this particular scenario. To best minimize further trauma, the nurse will provide the client with an explanation of all care (physical contact) that will take place. Attention is first focused on physical needs because the client appears to be in control emotionally at the moment. When the physical needs are met, the nurse will encourage the client to express her feelings; this is done most effectively once a therapeutic nurse-client relationship has been established. The last issue to be addressed in this scenario is that of potential health issues such as sexually transmitted diseases, HIV, and pregnancy.

The laboratory calls to report that a hospitalized client's lithium level is 1.9 mEq/L after 10 days of lithium therapy. How should the nurse respond to this information? 1 By monitoring the client closely because the level of lithium in the blood is slightly high 2 By notifying the practitioner of the findings because the level is dangerously high 3 By continuing the administration of the medication as prescribed because the level is within the therapeutic range 4 By reporting the finding to the practitioner so the dosage can be increased because the level is below the therapeutic range

2Any result above 1.5 mEq/L is approaching or in the toxic range. (The therapeutic range for lithium is 0.6 to 1.2 mEq/L.) Immediate action must be taken. The level is dangerously high, and continued administration of the drug and simple monitoring are unsafe.

An older adult tells the nurse, "I regret so many of the choices I've made during my life." Which of Erikson's developmental conflicts has the client probably failed to accomplish? 1 Autonomy versus shame and doubt 2 Ego integrity versus despair 3 Identity versus role confusion 4 Generativity versus stagnation

2The sense of ego integrity comes from satisfaction with life and acceptance of what has been and what is. Despair reflects guilt or remorse over what might have been. During puberty adolescents attempt to find themselves and integrate their own values with those of society; an inability to solve conflict results in confusion and hinders mastery of future roles. During early and middle adulthood the individual is concerned with the ability to produce and to care for that which is produced or created; failure during this stage leads to self-absorption or stagnation. Autonomy, the ability to control the body and environment, is developed during the toddler period; doubt may result when the child is made to feel ashamed or embarrassed.

A client on a medical unit refuses to eat and says, "The food is poisoned." The nurse should: 1 Ask the client what foods he wants so they can be ordered. 2 Encourage the client's family to bring favorite foods from home. 3 Suggest going to the cafeteria and selecting foods that the client feels safe eating. 4 Go with the client to the cafeteria and taste the food to show him that it is not poisoned.

3

A client with a conversion disorder is experiencing paralysis of a leg. The nurse can expect this client to: 1 Experience a spread of the paralysis to other body parts. 2 Require continuous psychiatric treatment to maintain independent function. 3 Recover use of the affected leg but, under stress, to again experience these symptoms. 4 Follow an unpredictable emotional course in the future, depending on exposure to stress.

3

en minutes before lunch, a client with obsessive-compulsive behavior begins the ritual of changing clothes for the fourth time. How should the nurse respond to this behavior? 1 Lead the client to the dining room and explain that the clothes can be changed after lunchtime. 2 Help the client change clothes quickly so lunch can be eaten at the scheduled time. 3 Tell the client to finish changing clothes and say that lunch can be eaten afterward. 4 Inform the client that everyone is required to be in the dining room at a specific time, so there is no time to change clothes.

3

When planning interventions to help a client with bipolar I disorder, manic episode, meet rest and sleep needs, the nurse must remember that the manic client: 1 Experiences few sleep pattern disturbances 2 Requires less sleep than the average person 3 Is easily stimulated, and this interferes with sleep 4 Needs to expend energy to be tired enough to sleep

3 Manic individuals readily respond to environmental cues. Increased stimulation increases activity; decreased stimulation decreases activity. Sleep pattern disturbances characteristically occur because of psychomotor activity. All individuals require adequate rest and sleep; hyperactive clients may become exhausted because of their high activity level. Expending energy only increases the tendency to remain awake.

A client is admitted voluntarily to a mental health unit. The client arrives on the unit and realizes that smoking is not permitted on the unit. At 2 am the client demands to leave the hospital because of the restriction on smoking. What should the nurse's first intervention be? 1 Allowing the client to leave 2 Calling the client's primary health care provider 3 Asking the client to submit a formal "72-hour letter" for release 4 Telling the client that the client's status will be changed to involuntary

3 A voluntarily admitted client must submit a formal written request 72 hours in advance for discharge. The 72-hour discharge request letter gives the primary health care provider 72 hours to assess the client's need for continued treatment. If a client is admitted voluntarily the admitting primary health care provider must confirm the need for admission and therefore must determine that the client is not a threat to himself or others and is appropriate for discharge. Even though the patient was admitted voluntarily, the health care provider must have concluded that the patient was a threat to himself or others or was gravely disabled to have admitted the client. Therefore the nurse cannot discharge the client without the primary health care provider's order. Because the health care provider corroborated the need for the client to be admitted, the health care provider probably would not change this conclusion several hours later. Because it is the middle of the night, the nurse should have the client submit a 72-hour letter. To prevent the client from becoming agitated the nurse should calmly explain this policy to the client. When a client who was admitted voluntarily asks to leave, the client's admission status is made involuntary. To prevent the client from becoming agitated, the nurse should calmly explain this policy to the client.

A nurse anticipates that most clients with phobias will use the defense mechanisms of: 1 Dissociation and denial 2 Introjection and sublimation 3 Projection and displacement 4 Substitution and reaction formation

3 Clients with phobias cope with anxiety by placing it on specific persons, objects, or situations through the displacement, projection, or both. The person with a phobia recognizes and admits the exaggerated fear as a real part of the self. Neither introjection, whereby a person internalizes and incorporates the traits of another, nor sublimation, whereby socially acceptable behavior is substituted for unacceptable instincts, is related to phobic activity. A less valued object is not substituted for one more highly valued (substitution), nor are the expressed feelings opposite the experienced feelings of fear (reaction formation).

An adolescent with a conduct disorder is undergoing behavioral therapy in an attempt to limit behaviors that violate societal norms. A specific outcome criterion unique to adolescents with this problem is: 1 Increased impulse control 2 Identification of two positive personal attributes 3 Demonstration of respect for the rights of others 4 Age-appropriate play activities with at least one peer

3 Demonstrating respect for the rights of others is a specific outcome criterion for children with a risk for violence directed at others; children with the diagnosis of conduct disorder typically present with a repetitive and persistent pattern of behavior that violates the basic rights of others or major age-appropriate societal norms or rules. Increased impulse control is a short-term goal for children with a variety of mental disorders of childhood such as attention deficit-hyperactivity disorder and oppositional defiant disorder. Identifying two positive personal attributes is a short-term goal for children who have disturbed self-esteem. Using age-appropriate play activities with at least one peer is a short-term goal for children who have impaired social interaction.

A client who has been on a psychiatric unit for several weeks continually talks about delusional topics. What response by the nurse is most therapeutic? 1 Asking the client to explain the delusion 2 Allowing the client to maintain the delusion 3 Encouraging the client to focus on reality issues 4 Explaining to the client why the thoughts are not true

3 Discussing reality-based issues helps decrease delusional and hallucinatory activity by reducing feelings of isolation and competition for sensory awareness. Asking the client to explain the delusions or allowing him to maintain them will support and reinforce the delusions and validate them. Explaining why the delusions are not true is a judgmental response that may decrease the client's trust and increase anxiety.

A nurse is caring for a 20-year-old client. According to Erikson's developmental psychosocial theory, what is expected by 20 years of age? 1 Having the capacity for love and a commitment to work 2 Being creative and productive and having concern for others 3 Having a coherent sense of self and plans for self-actualization 4 Accepting the worth, integrity, and uniqueness of one's past and present life

3 Having a coherent sense of self is a task of adolescence. By age 20 this goal should be achieved. Young adults, ages 18 to 35, should still be developing meaningful relationships and establishing themselves in careers. The stage of adulthood (generativity versus stagnation) is concerned with productivity, nurture, and support of the next generation. From age 65 to death, an individual should experience a feeling of the worth of his or her life.

A nurse notes that a male client sitting alone in the corner is smiling and talking to himself. Concluding that the client is hallucinating, the nurse should: 1 Ask the client why he is smiling. 2 Leave the client alone until he stops talking. 3 Invite the client to help decorate the dayroom. 4 Tell the client it is not good for him to talk to himself.

3 Inviting the client to help decorate the dayroom provides a stimulus that competes with and therefore reduces hallucinations. Asking the client why he is smiling is a direct question that the client probably cannot answer; also, it may increase anxiety. If the nurse waits for the client to stop hallucinating, there may be no chance for contact with this client. In addition to setting unrealistic standards, telling the client that it is not good to talk to himself fails to acknowledge that the client believes that the hallucinations are real.

A nurse is assessing an adolescent client with the diagnosis of schizophrenia, undifferentiated type. Which signs and symptoms should the nurse expect the client to experience? 1 Paranoid delusions and hypervigilance 2 Depression and psychomotor retardation 3 Loosened associations and hallucinations 4 Ritualistic behavior and obsessive thinking

3 Loosened associations and hallucinations are the primary behaviors associated with a thought disorder such as schizophrenia. Paranoid delusions and hypervigilance are more common in paranoid-type schizophrenia than in the undifferentiated type. Depression and psychomotor retardation are not characteristic of schizophrenia. Ritualistic behavior and obsessive thinking are generally associated with obsessive-compulsive disorders, not schizophrenia.

Naltrexone (Depade) is used to treat clients with substance abuse problems. In which situation does the nurse anticipate that naltrexone will be administered? 1 Treat opioid overdose. 2 Block the systemic effects of cocaine. 3 Decrease the recovering alcoholic's desire to drink alcohol. 4 Prevent severe withdrawal symptoms from antianxiety agents.

3 Naltrexone (Depade) is effective in reducing the risk of relapse among recovering alcoholics in conjunction with other types of therapy. Naloxone (Narcan), not naltrexone, is used for opioid overdose. Naltrexone is not used to treat the effects of cocaine. Naltrexone is an opioid antagonist. It is not used for antianxiety agent withdrawal.

vA client recently admitted to the psychiatric unit after an attempted suicide is placed in a private room with the curtains, telephone, and call light removed. A student nurse caring for this client on a one-to-one basis identifies that the client has become withdrawn and tends to sleep most of the time. What is the most appropriate nursing intervention? 1 Asking whether the client wants to rest or prefers to talk 2 Leaving the room quietly and allowing the client to sleep 3 Asking an open-ended question and sitting quietly by the client 4 Focusing on the client's behavior and requesting an explanation

3 Open-ended questions encourage the client to talk about topics of interest or concern without the nurse's imposing specific topics to be discussed. Sitting quietly shows concern and acceptance. Direct statements such as asking whether the client wants to rest or prefers to talk make it too easy for the client to say no and remain withdrawn. Prolonged sleeping is a sign of withdrawal and depression; the client should be encouraged to interact with the nurse. Focusing on the client's behavior and requesting an explanation is too confrontational at this time; the client may not be able to provide an explanation.

A female adolescent in group therapy tells the other group members that while out on a pass she used marijuana because her boyfriend made her smoke it. What defense mechanism is the client using? 1 Denial 2 Undoing 3 Projection 4 displacement

3 Projection involves blaming others for one's own difficulties or behaviors. Denial is defined as the unconscious refusal to admit an unacceptable idea or behavior. Undoing is defined as doing something to counteract or make up for a transgression or wrongdoing. Displacement is defined as discharging pent-up feelings to a less threatening object or person.

A client's history demonstrates a pervasive pattern of unstable and intense relationships, impulsiveness, inappropriate anger, manipulation, offensive behavior, and hostility. The admitting diagnosis is borderline personality disorder. What does the nurse anticipate that this client may attempt to do? 1 Act out to intimidate others. 2 Cooperate with the staff to gain praise. 3 Remain removed from others to avoid interacting with them. 4 Divide the staff into opposing factions to gain self-esteem.

3 SPLITTING Attempts at dividing the staff are expected because the resulting effect creates a feeling of power and control. These individuals usually act out to discharge anxiety rather than to intimidate. Usually they comply or cooperate to prevent a feeling of abandonment rather than to gain praise. Although such clients may remain removed from others to avoid interacting with them occasionally, they have an unstable approach and their aloofness cannot be maintained.

A nurse expects that when an individual successfully completes the grieving process after the death of a significant other, the individual will be able to: 1 Accept the inevitability of death. 2 Go on with life while forgetting the past. 3 Remember the significant other realistically. 4 Focus mainly on the good qualities of the person who died.

3 Successful resolution means being able to remember the good as well as the bad qualities of the deceased and accepting them as part of the deceased's being human. Resolution involves working through feelings, not just accepting what occurred. Resolution does not mean forgetting; rather it means realistically remembering the past. Focusing mainly on the good qualities of the person who died is an unhealthy response that may become pathological as a result of the unresolved feelings about the person's other qualities.

A client who has just experienced her second spontaneous abortion expresses anger toward the practitioner, the hospital, and the "rotten nursing care." When assessing the situation, the nurse concludes that the client may be using the coping mechanism of: 1 Denial 2 Projection 3 Displacement 4 Reaction formation

3 The client's anger about the miscarriage is shifted to the staff and the hospital because she is unable to cope with her loss at this time. The client is neither ignoring nor refusing to recognize reality. The client is not attributing unacceptable or undesirable thoughts or feelings to another; nor is she exhibiting a behavior pattern opposite what she feels.

A client with a long history of alcohol abuse who has been hospitalized for 1 week tells the nurse, "I feel much better and probably won't need any more treatment." What does the nurse conclude when evaluating the client's progress? 1 The client has accepted the illness and now must use willpower to resist alcohol. 2 The client will probably not use alcohol again as long as the client's family remains supportive. 3 The client's lack of insight into the emotional aspects of the illness indicates the need for continued supervision. 4 The client's statement should be communicated to the practitioner so aversion therapy can be started before the client's discharge.

3 The client's statement indicates denial. The basic problem that led to the alcoholism has not been resolved, and therefore continued supervision is required. It is not true that the client has accepted the illness and now must use willpower to resist alcohol; the client is still denying the illness, and willpower alone will not keep the client away from alcohol. It may be true that the client probably will not use alcohol again as long as the client's family remains supportive, but it does not ensure compliance or successful rehabilitation. Aversion therapy will not be helpful unless the client understands the basic problem and how to resolve it.

A client with an organic mental disorder becomes increasingly agitated and abusive. The practitioner prescribes haloperidol (Haldol). For what untoward effects should the nurse assess the client? 1 Jaundice and vomiting 2 Tardive dyskinesia and nausea 3 Parkinsonism and agranulocytosis 4 Hiccups and postural hypotension

3 The parkinsonian signs and symptoms are related to extrapyramidal tract effects, and agranulocytosis is related to bone marrow depression. Jaundice is an adverse reaction; vomiting is not. Tardive dyskinesia is an adverse reaction; nausea is not. The occurrence of orthostatic hypotension is low; hiccups usually do not occur.

One day the nurse and a young adult client sit together and draw. The client draws a face with horns and says, "This is me. I'm a devil." What is the best response by the nurse? 1 "I don't see a devil; why do you see a devil?" 2 "Let's go to the mirror to see what you look like." 3 "When I look at you I see a person, not a devil." 4 "You're not a devil; why do you talk about yourself like that?"

3 The response "When I look at you, I see a person, not a devil" points out reality while attempting to let the client understand that the nurse sees the client as a person of worth. The statement "I don't see a devil; why do you see a devil?" asks the client to explain his feelings, which may be unrealistic. The client may indeed view himself as a devil. The statement "You're not a devil; why do you talk about yourself like that?" is a somewhat belittling response; it cuts off communication.

The nurse working on the mental health unit finds a depressed client crying. What is the most therapeutic approach to help the client explore feelings? 1 "Does crying help?" 2 "I know that you're upset." 3 "Tell me what you're feeling now." 4 "Do you want to tell me why you're crying?"

3 The therapeutic "Tell me what you're feeling now" approach encourages expression of the client's feelings. "Does crying help?" does not explore feelings, and the client may interpret it as a put-down. Although "I know that you're upset" appears empathic, it does not encourage expression of feelings. "Do you want to tell me why you're crying?" will elicit a yes or no response rather than encouraging expression of feelings.

When a nurse is working with a client with psychiatric problems, a primary goal is the establishment of a therapeutic nurse-client relationship. What is the major purpose of this relationship? 1 Increasing nonverbal communication 2 Presenting an outlet for suppressed hostile feelings 3 Assisting the client in acquiring more effective behavior 4 Providing the client with someone who can make decisions

3 The therapeutic nurse-client relationship provides an opportunity for the client to try out different behaviors in an accepting atmosphere and ultimately to replace pathologic responses with more effective responses. Verbal communication, not nonverbal communication, is the objective of the therapeutic relationship. The nurse, although accepting of the client's hostile feelings, uses the therapeutic relationship to redirect hostile feelings into more acceptable behaviors. The nurse provides the support and acceptance that encourage clients to make their own decisions.

A daycare environment is recommended for a client with incapacitating behaviors resulting from an obsessive-compulsive personality disorder. The client's partner asks the nurse why this approach is necessary. What is the best response by the nurse? 1 "A location that requires no decision-making will resolve feelings of anxiety." 2 "The daycare setting allows the staff to exert control over unacceptable behaviors." 3 "A neutral atmosphere facilitates the working through of conflicts." 4 "This environment limits time to carry out the rituals."

3 These clients can better work through their underlying problems when the environment is structured, demands are reduced, and the routine is simple. Preventing these clients from carrying out rituals may precipitate panic reactions. Although eliminating the necessity to make decisions may decrease anxiety, simple decision-making should be encouraged. The intention of therapy should be to help the client gain control, not to enable others to do the controlling.

A nurse becomes aware of an older client's feeling of loneliness when the client states, "I only have a few friends. My daughter lives in another state and couldn't care less whether I live or die. She doesn't even know I'm in the hospital." The nurse identifies the client's communication as a: 1 Call for help to prevent him from acting on suicidal thoughts 2 Manipulative attempt to persuade the nurse to call the daughter 3 Reflection of depression that is causing feelings of hopelessness 4 Request for information about social support groups in the community

3 This statement provides clues that the client feels no one cares, so there is no reason the client should care. These feelings are common in depression. The clues presented do not lead to the other conclusions.

A client with schizophrenia is experiencing auditory hallucinations. A nurse makes the following statements when interacting with this client. Place these statements in the order in which they should be made. 1. "The voices you hear are part of your illness." 2. "Come with me for a walk." 3. "Hearing voices must be frightening." 4. "Let's play cards with another client in the recreation room." 5. "I don't hear any voices."

31524 The nurse should first identify the client's feelings. After the client's feelings have been identified, the nurse should then simply explain why the voices occur. Next the nurse should point out reality. The nurse should attempt to distract the client from the hallucination by engaging in a one-to-one activity; walking is a good choice because it will help the client discharge energy. Eventually the client may engage in a small group activity that may distract her from the hallucination.

en minutes before lunch, a client with obsessive-compulsive behavior begins the ritual of changing clothes for the fourth time. How should the nurse respond to this behavior? 1 Lead the client to the dining room and explain that the clothes can be changed after lunchtime. 2 Help the client change clothes quickly so lunch can be eaten at the scheduled time. 3 Tell the client to finish changing clothes and say that lunch can be eaten afterward. 4 Inform the client that everyone is required to be in the dining room at a specific time, so there is no time to change clothes.

33 Telling the client to finish changing clothes and explaining that lunch can be eaten afterward sets some limits on the compulsive act; it permits the ritual without reinforcing it but does not increase anxiety by removing the defense. Rushing the completion of the ritual will increase anxiety because the ritual is being used as a defense. Leading the client to the dining room and explaining that the clothes can be changed after lunch will increase the client's anxiety and reinforce the need for the behavior. Preventing the ritual will increase anxiety because the ritual is being used as a defense.

A nurse is interacting with a depressed, suicidal client. What themes in the client's conversation are of most concern to the nurse? Select all that apply. 1 Power 2 Betrayal 3 Loneliness 4 Hopelessness 5 Indecisiveness

34 Loneliness and a sense of isolation may play a role in the intent to commit suicide. A real or perceived lack of support increases the risk for suicide because there is no "lifeline of caring." The main factor leading to acting-out on suicidal impulses is the feeling of hopelessness; there are no longer reasons to live. The struggle for power and dominance is more commonly encountered in the verbalizations of clients with paranoid schizophrenia. Betrayal is a feeling more often verbalized by clients with a diagnosis of a borderline personality disorder. An indecisive individual usually will not make the decision to commit suicide.

nurse is aware that an older adult is at risk for social isolation as a result of certain factors. Select all that apply. 1 Wearing bilateral hearing aids 2 Being an insulin-dependent diabetic 3 Living alone since a spouse's death 3 years ago 4 Experiencing progressive macular degeneration 5 Requiring the weekly help of a home health aide 6 Employing a neighbor to provide assistance with grocery shopping

34 Social interaction can be impeded when an individual lives alone or is experiencing depression. A visual impairment can impede social interaction. A hearing impairment can impede social interaction, but the situation suggests that the problem is being managed and so would not be considered a negative factor. A chronic illness in and of itself does not qualify as a negative factor for socialization. Functional limitations can impede social interaction, but the situation suggests that the problem is being managed and so would not be considered a negative factor. Weekly interaction with a home health aide would be considered a positive factor. Experiencing functional limitations can impede social interaction, but the situation suggests that the problem is being managed and so would not be considered as a negative factor. Interaction with a neighbor would be considered a positive factor.

nurse receives a change-of-shift report on his clients. One client is on direct observation for acute suicidal ideation. Another client had a blood glucose of 400 mg/dL and was given 8 units of short-acting insulin just before the change of shift. A third client is pacing the unit, threatening staff with physical harm. A fourth client is in a bedroom, responding to internal stimuli. A fifth client is playing cards with another client. List the clients in the order in which they should be assessed by the nurse, from first to last. 1. Client with diabetes 2. Client who is suicidal 3. Client exhibiting aggressive behavior 4. Client responding to internal stimuli 5. Client playing cards with another client

34125 The client who is exhibiting aggressive behavior needs to be assessed first to prevent violent behavior against self and others. The client responding to internal stimuli (delusions or hallucinations) should be assessed second. The internal stimuli may precipitate aggressive behavior (e.g., command hallucinations). The client with diabetes who was given insulin should be assessed third. The client's response to the administration of insulin should be assessed. The suicidal client is under constant supervision and therefore is not the priority at this time. This client becomes the priority after the potentially aggressive clients and the physically unstable client are assessed. The client playing cards is in no distress and therefore may be assessed last.

A client with vascular dementia (formerly known as multiinfarct dementia) has signs and symptoms that are different from dementia of the Alzheimer type. What characteristics unique to vascular dementia should the nurse expect when assessing a client with this diagnosis? Select all that apply. 1 Memory impairment 2 Failure to identify objects 3 Exaggerated deep tendon reflexes 4 Episodic progression of symptoms 5 Inability to use words to communicate

34The diagnosis of vascular dementia is made when there is evidence of focal neurological signs and symptoms such as exaggerated deep tendon reflexes, extensor plantar response, gait abnormalities, and muscle weakness and computed tomography reveals multiple infarcts involving the cortex and underlying white matter. Usually the signs and symptoms associated with vascular dementia have a steplike progression because of further intermittent occlusion of small arteries or arterioles in the cortex of the brain. Dementia of the Alzheimer type is associated with a gradual, progressive loss of memory and cognitive abilities. Both vascular dementia and dementia of the Alzheimer type are associated with deficits in memory and cognition. Failure to identify objects despite intact sensory function (agnosia) is a cognitive disturbance associated with both vascular dementia and dementia of the Alzheimer type. Both vascular dementia and dementia of the Alzheimer type are associated with language disturbances such as inability to use or understand words (aphasia).

nurse who suspects that a newly admitted infant is the victim of child abuse assesses the parents' interaction with their baby. What parental behaviors might support the diagnosis of child abuse? Select all that apply. 1 Displaying sensitivity about their child care ability 2 Taking the initiative in meeting their child's needs 3 Exhibiting difficulty in showing concern for their child 4 Demonstrating heightened interest in their child's welfare 5 Procrastinating in obtaining treatment for their child's injuries

35 Abusive parents seek gratification of their own needs rather than of their child's needs; they may even project blame for the abuse on their child and find it difficult to conceal their hostility. Abusive parents often delay obtaining help for their child's injuries; the behavior is precipitated by a concern to conceal the injury and a lack of concern for the child. Abusive parents typically have an ill-developed nurturing role and little perception of their parenting inability.

A client is started on fluphenazine. What should the nurse emphasize in the teaching about this drug? Select all that apply. 1 "Driving is forbidden while you're taking this drug." 2 "You'll have a feeling of increased energy while taking this drug." 3 "You should increase your fluid intake to help prevent constipation." 4 "Your essential hypertension will be controlled indirectly by this drug." 5 "You need to use sunscreen for any outdoor activity, no matter what time of year."

35 Constipation is a frequent side effect of fluphenazine decanoate (Prolixin Deconate); increased dietary fluids and fiber help to limit constipation. Extreme photosensitivity is a common side effect of fluphenazine decanoate. Once the client's medication has been adjusted and the central nervous system response noted, driving may be permitted; drowsiness usually subsides after the first few weeks. Energy usually is decreased. Although this drug can cause hypotension, it does not consistently lower blood pressure.

A nurse provides crisis intervention for a client who recently left her husband because of physical abuse. Which client behaviors indicate to the nurse that the therapy has been successful? Select all that apply. 1 Is able to cry 2 Sleeps half the day 3 Utilizes healthier coping skills 4 Refuses a referral to support services 5 Describes the current situation realistically

35 Healthier coping provides a repertoire of skills from which to draw in future crisis situations. Being able to be objective and review the situation realistically demonstrates progress as the client moves toward resolution of the crisis. Although crying reflects that the client is expressing her feelings, usually it indicates the presence of anxiety and probably nonresolution of the crisis. Sleeping excessively is a maladaptive strategy. Refusing referrals to support services may indicate denial. One of the goals of crisis intervention is to develop a stronger support system.

A mother whose daughter has been killed in a school bus accident tells the nurse that her daughter was just getting over the chickenpox and did not want to go to school but she insisted that the girl go. The mother cries bitterly and says that her child's death is her fault. The nurse understands that perceiving a death as preventable most often will influence the grieving process in that it may: 1 Be easier to understand and to accept 2 Cause the mourner to experience a pathological grief reaction 3 Grow in intensity and duration 4 Progress to a psychiatric illness

3Deaths that are perceived as preventable cause more guilt for the mourners and therefore increases the intensity and duration of the grieving process. Perceiving a death as preventable will not necessarily result in a pathological reaction, but it will usually make it harder to understand and accept the death.

A nurse is counseling a recently widowed client, who says, "His death has complicated my life even more than the hassles he caused when he was alive!" The nurse realizes the client is having difficulty with the grieving process and nurse concludes that the relationship with the husband was probably: 1 Loving 2 Long-term 3 Subservient 4 Ambivalent

3If the relationship was ambivalent, the surviving spouse now has feelings of both anger and guilt to resolve. A loving relationship evokes fewer feelings of guilt and is followed by a less complicated grieving process. The length of the relationship seems to have little to do with the ease or difficulty in completing the grieving process. Individuals in the subservient role usually have learned to accept directions and either find a new director or are relieved to have a chance to express their own feelings.

A client is admitted to a long-term care facility and placed in a semiprivate room. After the second night on the unit the client's roommate reports that the client is masturbating at night and demands another room. What is the most appropriate intervention by the nurse? 1 Telling the roommate that this is acceptable behavior and that the client has the right to engage in it 2 Informing the client who is masturbating that this behavior is inappropriate and should not continue 3 Providing the client who was masturbating with periods of private time 4 Moving the roommate who made the report to another room

3Masturbating is a healthy human sexual behavior. The client should be provided with private time. The client has the right to meet physical needs but should not impose the behavior on others. Moving the roommate to another room could be ineffective because this may happen with the client's future roommate. Telling the roommate that this is acceptable behavior and that the client has the right to engage in it does not address either client's needs.

A 16-year-old high school student who has anorexia nervosa tells the school nurse that she thinks she that is pregnant even though she has had intercourse only once, more than a year ago. What is the most appropriate inference for the nurse to make about the student? 1 Using magical thinking 2 Submitting to peer pressure 3 Lying about the last time she had intercourse 4 Lacking knowledge that anorexia can cause amenorrhea

4

A client with a history of obsessive-compulsive behaviors has a marked decrease in symptoms and expresses a wish to obtain a part-time job. On the day of a job interview the client arrives at the mental health center with signs of anxiety. What is the most therapeutic response to the client's behavior by the nurse? 1 "I know you're anxious, but by forcing yourself to go to the interview you may conquer your fear." 2 "If going to an interview makes you this anxious, you're probably not ready to go back to work." 3 "It must be that you really don't want that job after all. I think you should reconsider going to the interview." 4 "Going for your interview triggered some feelings in you. Perhaps you could call a friend to drive you there."

4

A female client in the mental health clinic has pressured speech and mumbles incoherently. What is the most appropriate nursing intervention? 1 Setting limits on the client's behavior by refusing to talk with her unless she speaks clearly 2 Consistently asking the client to repeat what she has said so she will realize when she is mumbling 3 Ignoring the client's mumbling, because she is using this pathological manner of speech to gain attention 4 Indicating to the client that she needs to slow down because what she says is important and cannot be understood

4

A nurse encourages a client to attend Alcoholics Anonymous (AA) meetings after discharge. What do self-help groups such as AA help their members do? 1 Set long-term goals. 2 Limit excessive drinking. 3 Identify underlying causes of behavior. 4 Foster changes in behavior.

4

A nurse interviews a young female client with anorexia nervosa to obtain information for the nursing history. What will the client's history most likely reveal? 1 Close, supportive mother-daughter relationship 2 Satisfaction with and desire to maintain her current weight 3 Low level of achievement in school and little concern for grades 4 Strong desire to improve her body image

4

A nurse is caring for a newly admitted client with obsessive-compulsive disorder. When should the nurse anticipate that the client's anxiety level will increase? 1 As the day progresses 2 When family members visit 3 During a physical assessment by the nurse 4 When limits are set on the performance of a ritual

4

Three days after a stressful incident a client can no longer remember why it was stressful. The nurse, in relating to this client, can be most therapeutic by identifying that the inability to recall the situation is an example of the defense mechanism of: 1 Denial 2 Regression 3 Dissociation 4 Repression

4

What is the most important information for a nurse to teach to prevent relapse in a client with a psychiatric illness? 1 The need to develop a close support system 2 The need to create a stress-free environment 3 The need to refrain from activities that cause anxiety 4 The need to follow the prescribed medication regimen

4

In addition to hallucinating, a client yells and curses throughout the day. The nurse should: 1 Ignore the client's behavior. 2 Isolate the client until the behavior stops. 3 Explain the meaning of the behavior to the client. 4 Seek to understand what the behavior means to the client.

4 All behavior has meaning; before planning intervention, the nurse must try to understand what the behavior means to the client. Ignoring behavior does little to alter it and may even cause further acting-out. Isolation may increase anxiety and precipitate more acting-out behavior. The nurse cannot explain the meaning of the client's behavior; only the client can.

Bupropion (Wellbutrin) has a unique side effect not shared by most other drugs of its class. The nurse should assess the client for which unique possible side effect of this drug? 1 Heart failure 2 Breast tumors 3 Tardive dyskinesia 4 Generalized seizures

4 Bupropion (Wellbutrin) inhibits the reuptake of dopamine, serotonin, and norepinephrine and may cause seizures that can be life threatening; also, it may cause headaches, agitation, sedation, tremors, and confusion. Heart failure is not a side effect of bupropion. Tardive dyskinesia can occur with the use of neuroleptics.

A psychiatric nurse is working at a community mental health clinic. Which activity demonstrates that the nurse knows the importance of engaging in effective self-awareness? 1 Discussing with unit staff the role played by formal religion in personal happiness 2 Becoming aware of the cultural practices of the Hispanic clients served by the clinic 3 Refusing to engage in a discussion regarding alternative views on physician-assisted suicide 4 Accepting a client's decision to refuse electroconvulsive therapy as a treatment for chronic depression

4 Effective self-awareness is demonstrated by an accepting attitude toward clients' values, beliefs, and decisions when they differ from our own. Although formal religion is a source of happiness for many, but it is not an important component of life for everyone. Biases are not acted upon when a nurse is effectively self-aware. Cultural awareness is a component of good nursing practice. Knowledge of cultural practices in and of itself is not a reflection of acceptance, which is a necessary component of self awareness. Seeking alternative points of view is a characteristic of effective self-awareness because it aids in the acceptance of differing viewpoints.

A client with a history of substance abuse is brought to the emergency department. The client is having seizures, is hypertensive, and has hyperthermia. What drug should the nurse consider that the client may have been abusing? 1 Fentanyl 2 Alcohol 3 Oxycodone 4 Methamphetamine

4 Methamphetamine is a stimulant that increases the heart rate and blood pressure. It can cause hyperthermia, convulsions, and death. Alcohol is a central nervous system (CNS) depressant. Overdose of alcohol leads to a decreased level of consciousness and respiratory depression. Fentanyl and oxycodone are opioid and CNS depressants. Overdose leads to hypotension, a decreased level of consciousness, and respiratory depression.

The nurse teaches a client methods of coping with anger. The nurse concludes that the client has learned the most effective method when the client states that when she is angry she will: 1 Go for a long jog. 2 Go to the basement to scream. 3 Concentrate on what made her angry. 4 Talk about the anger

4 Talking about angry feelings is better than acting them out; this response indicates that the client has learned a positive coping method. Although taking a long jog or going to the basement to scream may help, it is an isolated activity that does not permit sharing of feelings and may not always be possible. Concentrating on what made the client angry may result in an escalation of angry feelings.

When caring for clients who are demonstrating manic behavior, the nurse must constantly reassess these clients' physical needs. What characteristic about these clients makes this particularly important? 1 Will withdraw to their rooms if left alone 2 Have difficulty making their needs known 3 May gain too much weight from overeating 4 May become exhausted from excessive activity

4 The elated client expends a great deal of energy; dehydration, oxygen deficit, cardiac problems, and death may occur. The elated person does not withdraw from reality but continues to run headfirst into reality. The elated client has little difficulty verbalizing needs. The elated client usually does not take time to eat while expending a great deal of energy, so weight loss is the problem.

On the third day of hospitalization, a client with a history of heavy drinking begins experiencing alcohol withdrawal delirium. What is the most appropriate response by the nurse when the client begins experiencing hallucinations? 1 Withholding intervention, because the client may be having vivid dreams 2 Asking the client to describe the hallucinations and explaining that they are not real 3 Pretending to visualize the imaginary things the client is describing to foster acceptance 4 Administering the prescribed medication to the client to subdue the agitated behavior

4 The nurse must administer the prescribed medication to the client to subdue the agitated behavior in this life-threatening situation. The client's central nervous system (CNS) is overstimulated, and seizures and death can occur. CNS-depressant medications, usually benzodiazepines, are needed to blunt the withdrawal effects. The client needs intervention because the hallucinations are not dreams. Focusing on the sensations associated with the withdrawal syndrome is not therapeutic; it is not helpful to tell the client that the hallucinations are not real, because they are real to the client. Validation reinforces the client's distorted perceptions of reality, is not helpful, and may be unsafe.

A client who has been sexually assaulted and is aware of the possible legal implications decides to seek prosecution of the rapist. The nurse carefully listens and documents all assessments. This is done because with a charge of rape the burden of proof: 1 Rests with the health team 2 Is on the defendant to prove innocence 3 Must be established before the case will be heard 4 Rests with the criminal justice system in collaboration with the victim

4 When the person who has been sexually assaulted chooses to seek prosecution of the rapist, the prosecutor must prove that rape occurred; the accused is innocent until proven guilty. The medical team may be asked to provide evidence at the trial, but the state, with the victim's help, must prove that the rapist is guilty. The perpetrator tries to establish innocence in a rape case. Guilt or innocence will be established by a jury, with the burden of proof placed on the victim.

A client undergoing alcohol detoxification asks about attending Alcoholics Anonymous (AA) meetings after discharge. What is the nurse's best initial reply? 1 "You'll find that you'll need their support." 2 "They'll help you to learn how to cope with your problem." 3 "Don't you think it's better to wait until you're sure that you're ready?" 4 "How do you feel about going to those meetings?"

4 "How do you feel about going to those meetings?" focuses on the client's feelings rather than on the organization itself. The organization is effective only when the client is able to discuss his feelings openly without ridicule or judgment. "You'll find that you'll need their support" may or may not be true. "They'll help you to learn how to cope with your problem" is false reassurance; AA may help clients develop insight but may not be able to help them cope with their problems. "Don't you think it's better to wait until you're sure that you're ready?" does not focus on the client's feelings and may be discouraging.

An older client with the diagnosis of dementia of the Alzheimer type is admitted to a long-term care facility. When planning care for this client, the nurse recalls that confusion: 1 Will be unchanged despite reality orientation 2 Is a common finding and is expected with aging 3 Results from brain changes that make interventions futile 4 Occurs with a transfer to new surroundings

4 A change in environment and introduction of unfamiliar stimuli precipitate confusion in clients with dementia-type disorders; with appropriate intervention, including frequent reorientation, confusion can be reduced. Reality orientation can reduce confusion when these clients are confronted with unfamiliar surroundings. The assertions that reality orientation is ineffective, that confusion is an expected finding in aging, and that brain changes in dementia make interventions futile are all untrue.

A couple arrives at the mental health clinic for counseling because the husband consistently believes that his wife is having multiple affairs. After several sessions a delusional disorder is diagnosed. What specific subtype of the delusion does the nurse identify? 1 Somatic 2 Grandiose 3 Persecutory 4 Jealousy

4 A client who is convinced that a mate is unfaithful exhibits delusional jealousy. Somatic delusions concern preoccupation with the body, including complaints of disfigurement, nonfunctioning body parts, insect infestation, and presence of a serious illness. In a grandiose delusion, the client seeks a position of power by expressing an exaggerated belief in his or her importance or identity. Clients with persecutory delusions believe that they are being conspired against, spied on, drugged, or poisoned.

An older client with a diagnosis of dementia is living in a long-term care facility. The client's daughter, who lives 300 miles away, calls the unit to speak to the nurse about her upcoming visit. What should the nurse say in response to her question about the best time of day to visit? 1 "Whenever is most convenient for you. She'll be glad to see you." 2 "Come at noon. You'll be able to go to the dining room and visit while she eats." 3 "The longest uninterrupted time begins after supper and extends until bedtime, at 8:30 pm." 4 "Around 2:30 in the afternoon is the best time to visit."

4 A client with dementia will be most alert in the midafternoon because of the presence of sunlight and decreased activity in the environment. Telling the daughter to come whenever it is most convenient for her does not take into consideration the client's circadian rhythms and stressors within the environment that may affect the client. As environmental stimuli increase, the client is at risk for increased confusion, restlessness, agitation, and combative behavior. The evening (after supper and continuing until bedtime, at 8:30 pm) is when the sundown syndrome occurs; clients with dementia exhibit increased confusion, restlessness, agitation, wandering, and combative behavior because of misinterpretation of the environment, lower tolerance for stress at the end of the day, or overstimulation resulting from increased environmental activity in the evening.

A female client who is severely incapacitated by obsessive-compulsive behavior has been admitted to the mental health hospital. The client's compulsive ritual involves changing her clothing eight to 12 times a day. She continually asks the nurse for advice regarding her problems but then ignores it. This is an example of the conflict of: 1 Apathy versus anger 2 Trust versus mistrust 3 Intimacy versus isolation 4 Dependence versus independence

4 A conflict exists between wanting to be taken care of and wanting to be self-reliant; ambivalence fosters lowered self-esteem. Apathy versus anger do not relate to the behavior described; people usually do not alternate these emotions, which are at opposite ends of the spectrum. Trust versus mistrust is the developmental conflict of the infant, according to Erikson; it is not related to the behavior described. Intimacy versus isolation is the developmental conflict of the young adult, according to Erikson; it is not related to the behavior described.

The ANA Guidelines on Psychopharmacology emphasizes that psychiatric-mental health nurses understand how psychotropic drugs affect neurotransmitter systems in the brain. Therefore the nurse should know that a decrease in γ-aminobutyric acid (GABA), according to the basic neurotransmitter theory, causes: 1 Depression 2 Paranoid schizophrenia 3 Dementia of the Alzheimer type 4 Anxiety

4 A decrease in GABA results in anxiety, according to the basic neurotransmitter theory; antianxiety drugs activate GABA receptors, thus opening chloride ion channels and easing anxiety. The neurotransmitters norepinephrine and serotonin are thought to be deficient in clients with depression; therefore specific psychotropic drugs cause an increase in the brain's ability to use these neurotransmitters. A simplistic explanation regarding the neurotransmitter system notes an excess in dopamine, which is related to schizophrenia; therefore antipsychotic drugs decrease the brain's ability to use this neurotransmitter. It is believed that a deficiency of acetylcholine, which is noted in dementia of the Alzheimer type, allows the buildup of amyloid; cholinesterase inhibitors such as benztropine (Cogentin) and donepezil (Aricept) slow the natural breakdown of acetylcholine by inhibiting the enzyme cholinesterase, which metabolizes acetylcholine.

A client is receiving haloperidol (Haldol) for agitation, and the nurse is monitoring the client for side effects. Which response identified by the nurse is unrelated to an extrapyramidal tract effect? 1 Akathisia 2 Opisthotonos 3 Oculogyric crisis 4 Hypertensive crisis

4 A hypertensive crisis is not associated with extrapyramidal tract symptoms. Akathisia, characterized by restlessness and twitching or crawling sensations in the muscles, is an extrapyramidal side effect. Opisthotonos, characterized by hyperextension and arching of the back, is an extrapyramidal side effect. Oculogyric crisis, characterized by the uncontrolled upward movement of the eyes, is an extrapyramidal side effect.

The nurse identifies that a client is expressing feelings of self-effacement. Which client assessment supports this conclusion? 1 Lack of initiative 2 Quiet monotone voice 3 Aggressive gestures and affect 4 Perception that no one is listening

4 A perception that no one is listening conveys to others that the client feels too insignificant for anyone to listen. Initiative and self-effacement are two different factors. A quiet monotone voice indicates feelings of sadness, not self-effacement. Aggressive behaviors are the opposite of self-effacing behaviors.

A 44-year-old single woman loses her job and has been unable to find a job for 8 months. She has exhausted her savings and is overwhelmed. She comes to the crisis intervention center because she is despondent and feels hopeless. What type of crisis does the nurse identify? 1 Subjective 2 Adventitious 3 Maturational 4 Situational

4 A situational crisis involves an unanticipated loss that is apparent to others. Examples include loss of a job, death of a loved one, and a change in health status such as an amputation. A subjective (internal) crisis threatens a person's well-being but is not obvious to others. Examples of subjective crises include aging, lack of independence, and loss of faith. An adventitious crisis involves natural (e.g., hurricane, tsunami) or man-made (e.g., arson, terrorist attack) traumatic events. These crises often involve numerous losses. A maturational crisis occurs in response to stress as a person experiences a predictable change. Examples of maturational crises include adolescence, marriage, parenthood, and retirement.

How should a nurse at an assisted living facility encourage a client to effectively complete the tasks of older adulthood? 1 By redefining the resident's role in society 2 By investing the resident's energies into nurturing others 3 By trying to complete missed opportunities with significant others 4 By fostering a sense of contentment when the client looks back on her achievements

4 Accepting one's past as meaningful and fulfilling is a sign of achieving the task of ego integrity. Redefining one's life indicates that ego integrity has not occurred. Investing the energies into nurturing others is a task of middle adulthood. An attempt to recapture lost opportunities is evidence of despair; it indicates that ego integrity has not been achieved.

The mother of an 18-year-old man comes to the local mental health center. She is extremely upset because of her son's behavior since the young man returned from his freshman year at college. He takes his brother's clothing, comes in at all hours, and refuses to get a job. Sometimes he is happy and outgoing, but at other times he is withdrawn. The mother asks why her son is like this. While contemplating this situation, the nurse considers that adolescents are usually: 1 Anxious and unhappy 2 Angry and irresponsible 3 Hyperactive and self-destructive 4 Impulsive and self-centered

4 Adolescence is a time of great upheaval and maturation. Before this maturational process is completed, adolescents act without thinking things through and are more concerned with their own needs, rather than the needs of others. The rapid and complex biological, social, and emotional changes during adolescence do not necessarily lead to these psychological responses.

The nurse suggests counseling for a 13-year-old whose close friend has just committed suicide. The nurse's intervention is based on the understanding that an adolescent is at risk for copycat suicide mainly because members of this age group: 1 Have had few experiences with mortality 2 Often forge very close peer relationships 3 Typically mimic the behavior of their peers

4 Adolescents are at especially high risk because of the immaturity of the prefrontal cortex. This is the portion of the brain that is responsible for judgment and impulse control. Although lack of life experience, the closeness of peer relationships, and behavioral mimicking are all characteristics of this age group, they are not as influential in a behavior such as copycat suicide.

On the psychiatric unit a client has been receiving high doses of haloperidol (Haldol) for 2 weeks. The client says, "I just can't sit still, and I feel jittery." Which side effect does the nurse suspect that the client is experiencing? 1 Torticollis 2 Tardive dyskinesia 3 Parkinsonian syndrome 4 Akathisia

4 Akathisia, a side effect of haloperidol (Haldol), develops early in therapy and is characterized by restlessness and agitation. Torticollis is characterized by a stiff neck (wry neck). Tardive dyskinesia is characterized by gross involuntary movements of the extremities, tongue, and facial muscles that develop after prolonged therapy. Pseudoparkinsonism is characterized by motor retardation, rigidity, and tremors; the reaction resembles Parkinson's syndrome but usually responds to decreasing the dose, the administration of an antidyskinetic medication, or discontinuation of the haloperidol.

During a group discussion it is learned that a group member hid suicidal urges and committed suicide several days ago. The nurse leading the group should be prepared to manage the: 1 Guilt of the co-leaders for failing to anticipate and prevent the suicide 2 Guilt of group members because they could not prevent another's suicide 3 Lack of concern over the suicide expressed by several of the members in the group 4 Fear by some members that their own suicidal urges may go unnoticed and that they may go unprotected

4 Ambivalence about life and death, plus the introspection commonly found in clients with emotional problems, can lead to increased anxiety and fear among the group members. These feelings must be handled within the support and supervisory systems for the staff; the group members are the primary concern. Guilt that the group's leaders or members might feel because they could not prevent another's suicide will probably be a secondary concern of the group leader. Lack of concern over the suicide expressed by several of the members in the group is not a primary concern, but this should be explored later to determine the reason for such apparent indifference, which may be a mask to cover true feelings.

It is most helpful to the nurse who is attempting to apply the principles of mental health to consider that: 1 People with emotional illnesses can empathize easily with others. 2 Emotionally ill people will initially reject psychological support. 3 Mental illness is characterized by signs and symptoms of socially inappropriate behavior. 4 Emotional health is promoted when there is a sense of mastery of self and the environment.

4 An individual must feel a sense of control over self and the environment to feel secure, reduce anxiety, and function at an optimum level. Most emotionally ill people are too introspective to empathize with others. Although some emotionally ill people will reject help, many are in pain and recognize that they need psychological support. Some clients actively seek out care on the basis of positive past experiences and the secondary gain of getting attention. Many individuals with mental illness do not demonstrate observable signs of socially inappropriate behavior.

An antianxiety medication is prescribed for an extremely anxious client. The client says, "I'm afraid to take these pills because I heard they're addictive." The nurse teaches the client that antianxiety medications: 1 May require increases in dosage but rarely cause dependence 2 Rarely cause dependence when the dosage is controlled 3 Usually result in psychological but not physiological dependence 4 Have the potential for physiological and psychological dependence

4 Antianxiety medications have the potential for physiological and psychological dependence; the nurse should teach the client about both the advantages and disadvantages of taking this drug. Physiological or psychological dependence may develop, even when the dosage is controlled. Tolerance does develop and can lead to dependence.

A nurse is caring for several clients who have severe psychiatric disorders. What is the major reason that a health care provider prescribes an antipsychotic medication for these clients? 1 To improve judgment 2 To promote social skills 3 To diminish neurotic behavior 4 To reduce the positive symptoms of psychosis

4 Antipsychotics are used to decrease positive signs and symptoms associated with psychoses, including hallucinations, delusions, paranoia, and disorganized speech. These drugs are used to minimize psychotic, not neurotic, signs and symptoms. Improved judgment and social skills are not prime reasons that antipsychotic drugs are used.

A nurse administers prescribed anxiolytics to clients with severe emotional disorders. What is the goal of this treatment? 1 Reduces antisocial symptoms 2 Limits secondary complications 3 Prevents destructiveness by the client 4 Makes the client more amenable to psychotherapy

4 Anxiolytics reduce the anxiety level and make clients more open to new strategies when coping with stress. Anxiolytics do not ease antisocial symptoms. They cannot prevent secondary complications. Preventing destructiveness by the client is not the major reason for their administration.

Nortriptyline (Pamelor) three times a day is prescribed for a depressed client. When does the nurse expect a therapeutic response? 1 1 to 3 days 2 12 to 24 hours 3 30 minutes to 2 hours 4 2 to 3 weeks

4 As with other tricyclics, optimal therapeutic effects take 2 to 3 weeks to occur. One to 3 days, 12 to 24 hours, and 30 minutes to 2 hours are all too soon to expect a response to nortriptyline.

During a group therapy session some members accuse another client of intellectualizing to avoid discussing feelings. The client asks whether the nurse agrees with the others. What is the best response by the nurse? 1 "It seems that way to me, too." 2 "What's your perception of my behavior?" 3 "I'd rather not give my personal opinion at this time." 4 "Are you uncomfortable with what you were told?"

4 Asking the confronted client whether he is uncomfortable with what he is being told will help the client identify behaviors and feelings in a nonthreatening manner. Agreeing with the confronting group members indicates a lack of acceptance of the client. The nurse's behavior is not the issue; the situation should be turned back to the client's behavior. Evasion and refusal to answer will have the psychological effect of removing the nurse from the group.

A client with a history of a short temper and physically abusive behavior becomes violent and is admitted to the psychiatric service. At the time of admission the client is extremely anxious. What is the priority nursing action? 1 Sitting quietly with the client 2 Encouraging the client to play video games 3 Introducing the client to several other clients 4 Assigning a staff member to supervise the client

4 Assigning a staff member to supervise the client will enable the staff member to respond quickly to any escalation in the client's mood or behavior. Sitting quietly with the client may put the nurse at risk because it may actually make the client more anxious and precipitate violence. The client is too anxious to concentrate on a game or to interact with other people.

A registered nurse (RN) in charge of a mental health unit has two additional staff members: a licensed practical nurse (LPN) and a nursing assistant (NA). The unit has 20 clients, with one client on constant observation for acute suicidality. What should the nurse in charge do when making the daily assignments? 1 Administer medications and assign the LPN to maintain observation of the suicidal client and the nursing assistant to provide client care. 2 Maintain constant observation of the suicidal client and assign the LPN to administer medications and the nursing assistant to provide client care. 3 Perform client care and administrative duties and assign the nursing assistant to administer medications and the LPN to maintain observation of the suicidal client. 4 Provide client care and administrative duties and assign the LPN to administer medications and the nursing assistant to maintain constant observation of the suicidal client.

4 Assigning the LPN to administer medications utilizes the LPN's skills; providing constant observation of a client is within the role of NAs and frees the RN to perform client care and administrative duties. Administering medications will keep the RN from performing administrative duties; having the LPN perform direct client observation will underutilize the abilities of the LPN. Providing suicide observation will prevent the RN from performing required administrative duties. Having an NA administer medications is illegal in many states. NAs are not educated about the actions and side effects of medications.

A client with a family history of diabetes is concerned about the effects of psychiatric medication on the endocrine system. Which psychotropic medication is most likely to cause metabolic syndrome? 1 Lithium (Carbolith) 2 Diazepam (Valium) 3 Alprazolam (Xanax) 4 Risperidone (Risperdal

4 Atypical antipsychotics, such as risperidone (Risperdal) can cause metabolic syndrome, in which the client experiences weight gain and increases in cholesterol and triglyceride levels. Diabetes mellitus and diabetic ketoacidosis may occur between 5 weeks and 17 months after initiation of therapy. Although lithium (Carbolith), diazepam (Valium), and alprazolam (Xanax) may cause weight gain, none causes metabolic syndrome.

A client is to begin lithium carbonate therapy. The nurse should ensure that before the drug's administration the client has baseline: 1 Liver enzyme studies 2 Adrenal function studies 3 Pulmonary function studies 4 Renal studies

4 Because of the severity of side effects and the stress lithium places on the renal and cardiovascular systems, its administration is contraindicated in clients with renal or cardiovascular disease. Baseline renal studies can be used for comparison in the future. Liver enzyme studies are not necessary; lithium does not alter liver function. Adrenal function studies are not necessary; lithium does not alter adrenal gland functions. Pulmonary function studies are not necessary; lithium does not cause alterations in pulmonary function.

What is an initial client objective in relation to anger management? 1 Expressing remorse over aggressive actions 2 Developing alternative methods to release feelings 3 Teaching others how to avoid triggering the angry behavior 4 Taking responsibility for the hostile behavior

4 Before progress can be made in treating anger, the client needs to take responsibility for the behavior. As long as the client blames others, there will be no motivation to change. The client may express remorse but continue to blame others and not feel the need for change. Developing alternative methods to release feelings is a worthwhile goal that is more appropriate later in therapy; it is not an initial goal. The client's own behavior needs to change; it is not appropriate in this situation to teach others to change.

The nurse is assigned to work with a 20-year-old client on an inpatient unit. In assessing the woman, the nurse notes that she is mute, does not show any type of movement, is unresponsive, and appears unaware of her surroundings. What is the best term for the nurse to use to describe these symptoms? 1 Alogia 2 Echopraxia 3 Affective flattening 4 Catatonia

4 Catatonia is the term to describe stupor, rigidity, or extreme flexibility of the limbs; excitability; confusion; and lack of verbal expression. Alogia is a term used to describe an inability to speak or near-absence of speech. Echopraxia is the term for the mimicking or repetition of the actions of another person. Affective flattening is the term for blunted or constricted facial expression.

A nurse is caring for a client with vascular dementia. What does the nurse expect of this client's mental status? 1 Diminished remote memory resulting from anoxia 2 Loss of abstract thinking related to emotional state 3 Inability to concentrate related to decreased stimuli 4 Difficulty recalling recent events related to cerebral hypoxia

4 Cell damage seems to interfere with how input stimuli are registered, which affects the ability to register and recall recent events; vascular dementia is related to multiple vascular lesions of the cerebral cortex and subcortical structures. The remote memory usually is not impaired to any great degree. The loss of abstract thinking is related to cell damage, not the emotional state. The inability to concentrate is related to cell damage, not decreased stimuli.

As a nurse enters a room and approaches a client who has schizophrenia, the client shouts, "Get out of here before I hit you! Go away!" The nurse concludes that this aggressive behavior is probably related to the fact that the client felt: 1 That voices are directing his behavior 2 Afraid of doing harm to the nurse if the nurse came closer 3 That the nurse was similar to someone who had frightened him in the past 4 Confined when the nurse walked into the room

4 Clients acutely ill with schizophrenia frequently do not trust others; feeling trapped may be frightening, causing them to lash out. There is no indication that voices are speaking to the client in this instance. Clients acutely ill with schizophrenia usually are more concerned with what is happening to them and are not able to be concerned about others. Although the nurse may have reminded the client of a threatening person from his past, it is not the primary motivation for this behavior.

The staff of a mental health unit is conducting an orientation meeting for newly admitted clients. What should the nurse plan to address first at the meeting? 1 Rules for client behavior 2 Clients' role and the leader's expectations 3 Development of trust between staff and clients 4 Purpose of the group meeting

4 Clients should know why they are there, what to expect, and what is to be accomplished. Rules for client behavior come after the explanation of the purpose of the group. Clients' role and the leader's expectations comes after the explanation of the purpose of the group. It is not necessary to define trust; the development of trust is a goal.

A psychologist has been a client on a mental health unit for 3 days. The client has questioned the authority of the treatment team, advised other clients that their treatment plans are wrong, and been disruptive in group therapy. What is the most appropriate nursing intervention? 1 Telling the other clients to disregard what the client is saying 2 Ignoring the client's disruptive behavior and waiting for it to subside 3 Restricting the client's contact with other clients until the disruptive behavior ceases 4 Accepting that the client is unable to control this behavior and setting appropriate limits

4 Clients who are out of control need to have limits set for them. The staff must understand that the client is not deliberately trying to disrupt the unit. Telling the other clients to disregard what the client is saying is demeaning the client in the eyes of the other clients and does not address the problem directly. Ignoring the client will not stop the disruptive behavior; also, the nurse has a responsibility to the other clients. Restricting the client's contact with other clients until the disruptive behavior ceases may be done as a last resort, but this approach should not be used until other alternatives have been explored.

Hospitalization or day-treatment centers are often indicated for the treatment of a client with obsessive-compulsive disorder because these settings: 1 Prevent the client from completing rituals. 2 Allow the staff to exert control over the client's activities. 3 Resolve the client's anxiety because decision making is minimal. 4 Provide the neutral environment the client needs to work through conflicts.

4 Clients with obsessive-compulsive disorder can work through their underlying conflicts more easily or productively when demands are reduced and the routine is simple. Preventing such a client from carrying out rituals can precipitate a panic reaction. The intent of therapy should be to help the client gain control, not to enable others to do the controlling. Because anxiety stems from unconscious conflicts, a controlled environment alone is not enough to produce resolution.

A nurse is educating a client who is taking clozapine (Clozaril) for paranoid schizophrenia. What should the nurse emphasize about the side effects of clozapine? 1 Risk for falls 2 Inability to sit still 3 Dizziness upon standing 4 Increase in temperature

4 Clozapine (Clozaril) may cause agranulocytosis, which can result in the development of infection. Risk for falls is more common with typical antipsychotic medications because they may cause orthostatic hypotension and extrapyramidal side effects. Inability to sit still (akathisia) and dizziness upon standing (orthostatic hypotension) are more common with typical antipsychotics because they may cause extrapyramidal side effects.

A client who has a long history of alcoholism has not worked for the past 10 years. When the nurse asks about daily activities the client responds, "I currently work in the office of a local construction company." Which mental mechanism should the nurse suspect that the client is using? 1 Regression 2 Sublimation 3 Compensation 4 Confabulation

4 Confabulation is often used by people with alcoholism to cover lapses of memory that occur with Korsakoff syndrome; it is an unconscious means of self-protection. Regression is a return to a prior stage of development as a way to cope with stress. Sublimation is the channeling of unacceptable thoughts and feelings into socially acceptable behaviors. Compensation is replacement of a real or imagined deficit with a more positive attribute or trait.

In response to a question posed during a group meeting, the nurse explains that the superego is that part of the self that says: 1 "I like what I want." 2 "I want what I want." 3 "I can wait for what I want." 4 "I shouldn't want that."

4 Conscience and a sense of right and wrong are expressed in the superego, which acts to counterbalance the id's desire for immediate gratification. "I like what I want" does not reflect any part of the self. "I want what I want" is the id seeking satisfaction. A healthy ego can delay gratification and is in balance with reality.

What is the priority goal in the planning of care for a client in crisis? 1 Referring the client for occupational therapy 2 Arranging follow-up counseling for the client 3 Having the client work to gain insight into the problem 4 Restoring the client's psychological equilibrium

4 Crisis intervention is short-term therapy with the major goal of restoring the client to the precrisis state. Referring the client for occupational therapy is not a goal but an action to help achieve a goal; it is not part of crisis intervention. Scheduling the client for follow-up counseling is not a goal but rather an intervention that may be necessary if psychological equilibrium cannot be restored. Having the client gain insight into the problem is not always necessary for a client to be able to function effectively.

nurse discusses the plan of care with a depressed client whose husband has recently died. The nurse determines that it will be most helpful to: 1 Involve the client in group exercises and games. 2 Encourage the client to talk about and plan for the future. 3 Motivate the client to interact with male clients and the nursing staff. 4 Talk with the client about her husband and the details of his death.

4 Discussing the partner and the partner's death will help the client work through the grief process. Involving the client in group exercises and games refocuses the client's attention away from addressing feelings; the client probably does not have the physical or emotional energy to get involved with group activities. The client must cope with the past and present before addressing the future. Motivating the client to interact with male clients and the nursing staff refocuses the client's attention away from addressing feelings; the client probably does not have the physical or emotional energy to get involved with others.

A nurse assesses a client recently admitted to an alcohol detoxification unit. What common clinical manifestation should the nurse expect during the initial stage of alcohol detoxification? 1 Euphoria 2 Bradycardia 3 Hypotension 4 Nausea

4 During the first stage of alcohol detoxification, nausea and anorexia are expected. Irritability, not euphoria, is experienced during this stage. Tachycardia, not bradycardia, is experienced during this stage. Hypertension, not hypotension, is experienced during this stage.

The nurse manager of a mental health unit regularly includes effective boundary-setting as a topic for the monthly staff in-service education sessions. What is the primary principle behind this decision? 1 Nurses are caring people who are willing to make exceptions for needy clients. 2 Staff members may have trouble establishing boundaries with manipulative clients. 3 Mental health clients often demonstrate difficulties establishing healthy boundaries. 4 Staff members are at risk for problems with boundary-setting.

4 Effective boundary-setting is a vital component of an effective, therapeutic nurse-client relationship. Staff members are at risk for failing to establish such boundaries, especially with specific clients; this then allows overinvolvement and the development of a nontherapeutic environment. Although it is true that nurses are generally caring people, it is not true that they are likely to ignore boundary-setting principles. Although manipulative clients may challenge the boundaries established for a therapeutic relationship, another principle is more relevant to the manager's decision. The focus of this training is on the nurse's ability to set appropriate professional boundaries, not to help clients set appropriate interpersonal boundaries.

One morning, during the working phase of a therapeutic relationship after several sessions in which difficult issues were discussed, the client suddenly becomes very hostile. What is the most appropriate interpretation of this behavior by the nurse? 1 The client is exercising assertiveness, which implies improvement. 2 Flare-ups often occur even when there is a positive working relationship. 3 The behavior is a form of regression, which implies some deterioration in the client's condition. 4 Hostility is being used as a defense because previous self-disclosure has raised anxiety.

4 Emotional closeness after self-disclosure increases anxiety, which cannot be tolerated; hostility is used to keep the nurse at a distance. Hostility is more extreme than assertiveness and is not an indication of improvement. Although flare-ups often occur even when there is a positive working relationship, the expression of hostility is not a flare-up in this situation. Regressive behavior is the resumption of behavior characteristic of an earlier stage of development; hostility does not fit this definition.

Suicide precautions are ordered for a newly admitted client. What is the most therapeutic way to provide these precautions? 1 Keeping the client in the lounge during the daytime 2 Encouraging the client to express feelings frequently 3 Having a nursing aide observe the client every half hour at night 4 Assigning a staff member to be with the client at all times

4 Emotional support and close surveillance can demonstrate the staff's caring and their attempt to prevent the client from acting out of suicidal ideation. Although surveillance may meet the client's safety needs, it does not meet the client's emotional needs. Also, the client would still have the opportunity to attempt suicide at night. Encouraging the client to express feelings frequently is not a suicide precaution. Having a nursing aide check the client every half hour at night is unsafe; the client could still find a way to carry out a suicide attempt in the room.

What is the most appropriate nursing intervention when a client is seen openly masturbating in the recreation room? 1 Restraining the client's hands 2 Putting the client in seclusion 3 Teaching the client acceptable behavior 4 Escorting the client from the room

4 Escorting the client from the room accepts the client but rejects the behavior. The nurse should set limits on this behavior when it is not performed in a private area. Restraining the client's hands is unrealistic and violates the client's rights. Putting the client in seclusion is a punishment rather than a setting of limits. The client may be too anxious at this time to understand a conversation about acceptable and unacceptable behavior. The nurse has a responsibility to the other clients to limit the behavior.

A client is admitted to a psychiatric hospital because of a recurrent mental health problem. During admission the nurse determines the expected client outcomes. The nurse concludes that these outcomes are: 1 Long-term goals 2 Variances of care 3 Clinical pathways 4 Measurable objectives

4 Expected outcomes are the desirable projected responses to therapeutic interventions that consider the client's present and potential capabilities; they are measurable and realistic. Expected outcomes may be either short-term or long-term, not only long-term. A variance is when a client's response to interventions is different from what usually is expected. Expected client outcomes are a component of a clinical pathway; a clinical pathway is a written standardized process that identifies projected provider behaviors and interventions and expected client outcomes based on the client's diagnosis.

A situational crisis involves an unanticipated loss that is apparent to others. Examples include loss of a job, death of a loved one, and a change in health status such as an amputation. A subjective (internal) crisis threatens a person's well-being but is not obvious to others. Examples of subjective crises include aging, lack of independence, and loss of faith. An adventitious crisis involves natural (e.g., hurricane, tsunami) or man-made (e.g., arson, terrorist attack) traumatic events. These crises often involve numerous losses. A maturational crisis occurs in response to stress as a person experiences a predictable change. Examples of maturational crises include adolescence, marriage, parenthood, and retirement.

4 Families who are informed about the client's status can help with treatment goals and discharge planning. Relief of anxiety, relaxation, and fewer nursing problems may all be secondary gains, but none is the primary purpose.

Lithium carbonate 600 mg by mouth three times a day is prescribed for a client. The nurse concludes that the teaching about its side effects is understood when the client says that she will call her primary health care provider immediately if she notices any: 1 Difficulty urinating 2 Sensitivity to bright light or sun 3 Sexual dysfunction or breast enlargement 4 Fine hand tremor or slurred speech

4 Fine hand tremor or slurred speech in a person taking lithium may signal the development of toxicity; signs of toxicity include marked tremors, lack of coordination, sluggishness, and confusion. Lithium carbonate can cause polyuria and incontinence, not urine retention. Sensitivity to bright light or sun is a side effect of the phenothiazine group of medications. Neither sexual dysfunction nor breast enlargement is associated with lithium carbonate intake.

A client with schizophrenia sees a group of visitors sitting together talking. The client tells the nurse, "I know they're talking about me." Which altered thought process should the nurse identify? 1 Flight of ideas 2 Grandiose delusion 3 Thought broadcasting 4 Ideas of reference

4 Ideas of reference, seen with psychotic thinking, is a delusional belief that others are talking about the client. Flight of ideas is the rapid thinking seen in clients in a manic state. Grandiose delusions are irrational beliefs that overestimate one's ability or worth. Thought broadcasting is the delusional belief that others can read one's thoughts.

An older client whose family has been visiting him in the psychiatric unit is visibly angry and says to the nurse, "My daughter-in-law says they can't take me home until the doctor lets me go. She doesn't understand how important this is to me; she's not from our culture." What should the nurse do? 1 Ignore the statement for the present. 2 Reflect on the client's feelings about the cultural differences. 3 Respond, "The doctor is the one who makes decisions about discharge." 4 Say, "You feel she doesn't want you at home."

4 Identifying and accepting feelings help to open lines of communication. Ignoring the statement for the present does not allow the client to explore feelings with an accepting person. Reflecting on the client's feelings about the cultural differences focuses on only one aspect of the statement; it does not allow exploration of feelings. Explaining that the health care provider makes the decisions about discharge avoids the real issue.

A client who has been experiencing excessive stress is hospitalized because of an inability to walk. After a physiological basis for the problem is ruled out, a diagnosis of somatoform disorder, conversion type, is made. The nurse concludes that the client's paralysis is a: 1 Nondisabling illness 2 Way to get attention 3 Loss of contact with reality 4 Result of intrapsychic conflict

4 In situations in which a client may experience a high level of anxiety and psychic pain, a physical reason for not acting may unconsciously be used to limit negative feelings. Somatoform disorders are disabling; the client truly believes that the symptoms are real. These individuals do not enjoy their illness; their anxiety is relieved by it. These individuals are in contact with reality.

The nurse is caring for a client with dementia whose expression of emotions is altered. Which behavior is unexpected with this client? 1 Lability 2 Passivity 3 Withdrawal 4 Curiosity

4 Intellectual deterioration associated with dementia decreases interest in the environment. Diffuse impairment of brain tissue function results in fluctuations in the extremes of emotions; lability of mood is common with dementia. Clients with dementia usually fluctuate between aggressive acting out and passive acceptance. In clients with dementia, intellectual deterioration can result in behavior that mimics withdrawal.

A client is admitted to the hospital with a history of increasingly bizarre behavior. The client says, "I'm wired to the TV, and it told me that my family is out to kill me." What is the best initial action by the admitting nurse? 1 Taking the client to the dayroom and introducing the other clients on the unit 2 Reassuring the client that the unit is safe and that the client will be protected from the family 3 Telling the client that the door is locked and that no one will be permitted to enter the unit to harm anyone 4 Introducing the client to the primary nurse who will be assigned to work on a one-to-one basis with the client

4 Introducing the client to the primary nurse who will be assigned to work on a one-to-one basis with the client is extremely important because the client can be assisted back to reality by a nurse who is interested in her and her feelings. It can also start to build the therapeutic relationship which will be the foundation of trust. Taking the client to the dayroom and introducing the other clients on the unit should come later. Reassuring the client that the unit is safe and that the client will be protected from the family is false reassurance that the client will not believe. Telling the client that the door is locked and that no one will be permitted to enter the unit to harm anyone will have no effect because the client is under a strong delusion.

An effective mood-stabilizing drug used in clients with bipolar disorder in the acute treatment of mania and prevention of recurrent mania and depressive episodes is: 1 Doxepin (Sinequan) 2 Clozapine (Clozaril) 3 Amitriptyline (Elavil) 4 Lithium carbonate (Lithium)

4 Lithium carbonate is often the first choice of treatment, once primary acute mania has been diagnosed, to calm acute manic symptoms and relieve recurrent mania. Doxepin and amitriptyline are antidepressants used to treat depression but not mania. Clozaril is an antipsychotic medication used to control hallucinations and delusions in patients with psychosis but is not a first-line drug because of its side effects, which include seizures and significant weight gain.

A nurse is discussing plans with a client who has decided to withdraw from alcohol. What should the nurse recommend as one of the most effective treatments for alcoholism? 1 Individual or group psychotherapy 2 Admission to an alcoholic unit in a hospital 3 Daily administration of disulfiram (Antabuse) 4 Active membership in Alcoholics Anonymous

4 Members find empathy, patience, and understanding in Alcoholics Anonymous (AA). They are able to have their dependence needs met while helping others who are even more dependent. Individual or group psychotherapy is helpful, but it does not have the success rate of AA. Admission to an alcoholic unit in a hospital is important for the detoxification stage, not for overall therapy. Daily administration of disulfiram (Antabuse) may be helpful for some clients, but it does not have the success rate of AA.

What is the planned effect of naloxone when it is administered for a heroin overdose? 1 To prevent excessive withdrawal symptoms as heroin wears off 2 To accelerate metabolism of heroin and stimulate respiratory centers 3 To stimulate cortical sites that control consciousness and cardiovascular function 4 To compete with opioids for receptors that control respiration

4 Naloxone is used to treat opioid-induced apnea. It competes with the opioid for central nervous system receptor sites and thus acts as an opioid antagonist. Preventing excessive withdrawal symptoms as heroin wears off is not the specific action of this drug. Naloxone does not accelerate the metabolism of heroin. Stimulating cortical sites that control consciousness and cardiovascular function is not the action of naloxone. One adverse reaction of naloxone is cardiovascular irritability.

A 20-year-old student comes to the college health clinic reporting increasing anxiety, loss of appetite, and an inability to concentrate. What is the most therapeutic response by the nurse? 1 "Who have you shared your feelings of anxiety with?" 2 "What have you identified as the cause of your anxiety?" 3 "Let's talk about your problems. Are you having difficulty adjusting?" 4 "It's been difficult for you. How long has this been going on?"

4 Noting that the situation has been difficult for the client and asking how long it has lasted acknowledges feelings and attempts to collect more data. Asking whom the client has shared the situation with will not facilitate the collection of data about the extent of anxiety. Anxiety is most often a response to a vague, nonspecific threat; the client will not be able to explain what causes it. It is too early to try to identify the cause of the anxiety; crisis intervention with anxious clients requires a more structured approach than "Let's talk."

A nurse is teaching clients about dietary restrictions during monoamine oxidase inhibitor (MAOI) therapy. What response does the nurse tell them to anticipate if they do not follow these restrictions? 1 Generalized urticaria 2 Severe muscle spasms 3 Sudden drop in blood pressure 4 Occipital headaches

4 Occipital headaches are the beginning of a hypertensive crisis resulting from an excess of tyramine. Generalized urticaria is unrelated to the ingestion of tyramine. Severe muscle spasms are unrelated to the ingestion of tyramine. Excessive tyramine causes an increase, not a decrease, in blood pressure.

A nurse working on a mental health unit is caring for several clients who are at risk for suicide. Which client is at the greatest risk for successful suicide? 1 Young adult who is acutely psychotic 2 Adolescent who was recently sexually abused 3 Middle-age woman experiencing dysfunctional grieving 4 Older single man just found to have pancreatic cancer

4 Older single men with chronic health problems are at the highest risk of suicide. This is because men have fewer social supports than women do. (Men are less social then women in general.) Less social support at times of stress can increase the risk of suicide. Also, chronic health problems can lead to learned helplessness, which can lead to depression. People who are acutely psychotic as a group are at higher risk for suicide, but they do not have the suicide rate of older single adult men with chronic health problems. An adolescent who was recently sexually abused, although severely traumatized, does not have the risk of suicide of an elderly single man with chronic health problems. Dysfunctional grieving is prolonged grieving that is characterized by greater disability and dysfunctional patterns of behavior. Although people with complicated dysfunctional grieving may be at risk for self-directed violence, they do not have the suicide risk of elderly single men with chronic health problems.

A client with a history of violence is becoming increasingly agitated. Which nursing intervention will most likely increase the risk of acting-out behavior? 1 Being assertive 2 Responding early 3 Providing choices 4 Teaching relaxation

4 Once the client is agitated, teaching will not be effective and may increase the client's anxiety. Teaching relaxation techniques can be done once the client calms down. Being assertive (not aggressive) shows the client that the nurse is confident in handling the situation. This may help reduce the client's anxiety. Responding before agitation escalates makes interventions more likely to be successful. Providing choices may help the client feel less threatened and avoids a power struggle.

A client with recurrent episodes of depression comes to the mental health clinic for a routine follow-up visit. The nurse suspects that the client is at increased risk for suicide. What is a contributing factor to the client's risk for suicide? 1 Psychomotor retardation 2 Decreased physical activity 3 Deliberate thoughtful behavior 4 Overwhelming feelings of guilt

4 Overwhelming feelings of guilt contribute to the client's risk for suicide. The client may ruminate over past or current failings, and extreme guilt can assume psychotic proportions. Psychomotor retardation and decreased physical activity are clinical findings associated with depression and usually do not lead to suicide because the client does not have the energy for self-harm. Impulsive behaviors, not deliberate thoughtful behaviors, contribute to the client's risk for suicide.

What therapeutic nursing intervention may redirect a hyperactive, manic client? 1 Suggesting that the client write a short story 2 Having the client initiate group social activities on the unit 3 Asking the client to guide other clients as they clean their rooms 4 Encouraging the client to tear pictures out of magazines for a scrapbook

4 Physical activity will help the client expend some of the excess energy without requiring him to make decisions or forcing other clients to deal with the behavior. The client's extreme activity limits his capacity for concentration or task completion. The client may disrupt the unit because of the excess activity and bossiness associated with this disorder. The client needs guidance and is not able to guide others.

A health care provider refers a 52-year-old man to the mental health clinic. The history reveals that the man lost his wife to colon cancer 6 months ago and that since that time he has seen his health care provider seven times with the concern that he has colon cancer. All tests have had negative results. Recently the client stopped seeing friends, dropped his hobbies, and stayed home to rest. Which disorder should the nurse identify as consistent with the client's preoccupation with the fear of having a serious disease? 1 Conversion disorder 2 Somatization disorder 3 Body dysmorphic disorder 4 Hypochondriac disorder

4 Preoccupation with fears of getting or having a serious disease is called hypochondriasis. The condition usually exists for 6 months or longer, persists despite negative medical tests and reassurance, and results in social or occupational impairment. Conversion disorder is characterized by the presence of one or more symptoms related to a neurological problem that has no organic cause. Somatization disorder is characterized by the reporting of many physical problems by the client, usually beginning before age 30; physical problems may include pain, gastrointestinal symptoms, sexual or reproductive problems, and at least one symptom that suggest a neurological disorder. Body dysmorphic disorder is characterized by preoccupation with some imagined defect in appearance that causes marked distress and significant impairment in social and occupational function.

It is lunchtime at a mental health facility, and a 27-year-old client is unable to open her door because she has run out of the paper towels she uses to avoid touching the doorknob. What is the priority intervention by the nurse? 1 Exploring the feelings that triggered her use of the ritual for opening doors 2 Encouraging her to open the door if she expects to leave for the dining room 3 Opening the door for her and telling her that the staff will try to find more towels 4 Giving her a supply of paper towels and then sending her to the dining room for lunch

4 Providing paper towels takes into consideration the fact that the client's anxiety will increase if the ritual is interrupted; this allows the client to complete the ritual and encourages her to go to the dining room for lunch. Exploring feelings at this time is inappropriate because it will increase anxiety and result in the client's missing a meal. Having the client open the door without performing the ritual denies the ritual, which will result in an increase in anxiety. Opening the door for the client will precipitate a conflict between completing the ritual and going to the dining room; this conflict will increase anxiety.

A hyperactive client with bipolar I disorder becomes loud and insulting and says to a staff member, "Get lost, you old buzzard!" The nurse can best handle this situation by: 1 Asking the client to explain why he is so angry 2 Pointing out that the staff member is neither old nor a buzzard 3 Telling the client that if the rude behavior does not change there will be consequences 4 Asking the client to come with her for a walk

4 Rather than placing emphasis on their behavior, staff members should use the easy distractibility of these clients to redirect manic behavior to more constructive channels. A walk with the nurse provides structure and a way to expend energy safely. The client will be unable to explain the basis for the expressed anger to the nurse. Pointing out that the staff member is neither old nor a buzzard encourages the client to defend the statement; it does not foster communication about feelings. Telling the client that if the rude behavior does not change there will be consequences focuses on the behavior; it is a punitive response that does not foster communication.

A client is found to have generalized anxiety disorder. For what behavior should the nurse assess the client to determine the effectiveness of therapy? 1 Participating in activities 2 Learning how to avoid anxiety 3 Taking medications as prescribed 4 Recognizing when anxiety is developing

4 Recognition of anxiety or symptoms of increasing anxiety is an indication that the client is improving. Avoidance of anxiety is not a good indication of improvement; there is no guarantee that anxiety can always be avoided. Participating in activities and taking medications as prescribed do not indicate improvement or recognition of feelings; the client may be doing what others expect. `

A nurse speaks with a client who has just experienced a panic attack. Which statement will be the most therapeutic in addressing the client's concerns? 1 "I would have been upset, too." 2 "Episodes like this one can be upsetting even though they do end." 3 "Your family must have thought that you were having a heart attack." 4 "You are concerned that this might happen again"

4 Recurrence of attacks is a common concern. Stating that the nurse would have been upset too redirects the focus to the nurse, which is not therapeutic. Although recognizing that the panic attack must have been upsetting initially focuses on feelings, communication is then cut off when the nurse remarks that they do end. The focus should be on the client, not what the family believes.

A nurse is assessing a client with the diagnosis of schizophrenia, undifferentiated type. What defense mechanisms should the nurse anticipate that this client might use? 1 Projection 2 Repression 3 Conversion 4 Regression

4 Regression is an unconscious defense mechanism that reduces anxiety by returning to behavior that was successful in earlier years. Regression commonly is used by clients with undifferentiated schizophrenia to reduce anxiety. Projection is the attributing of unacceptable feelings or thoughts to others. It is an organized defense used by clients with paranoid, not undifferentiated, schizophrenia. Clients with undifferentiated schizophrenia have psychotic manifestations that are extreme and do not have thought processes effective enough to use projection. Repression is unintentionally putting disturbing thoughts, feelings, or desires out of the conscious mind. Clients with schizophrenia are not able to do this and therefore have a need to escape from reality. Conversion is an unconscious defense mechanism in which a person develops physical symptoms that have no organic cause. Conversion serves the purpose of reducing anxiety. Conversion is not used by clients with undifferentiated schizophrenia.

The nurse at the mental health clinic is counseling a client with obsessive-compulsive disorder who spends a lot of time each day engaged in handwashing and has trouble keeping appointments on time as a result. What is the most therapeutic initial intervention by the nurse? 1 Discouraging the frequent handwashing to prevent skin breakdown 2 Encouraging the client to hasten the ritual so appointments can be kept on time 3 Telling the client how angry others become when activities are delayed for handwashing 4 Accepting the ritualistic behavior with a matter-of-fact attitude without displaying criticism

4 Responding to the ritualistic behavior in a matter-of-fact way avoids reinforcing the behavior; allowing time for rituals helps prevent an increase in the anxiety level. Attempts to discourage ritualistic behavior often increase the anxiety level and intensify the performance of the ritual. Attempts to hasten ritualistic behavior will increase the level of anxiety. Disparaging the client will decrease self-esteem, will increase anxiety and guilt, and may worsen the client's symptoms.

The multidisciplinary team decides to use a behavior modification approach for a young woman with anorexia nervosa. Which planned nursing intervention is an appropriate approach to use with this client? 1 Having the client role-play interactions with her parents 2 Providing the client with a high-calorie, high-protein diet 3 Forcing the client to talk about her favorite foods for 1 hour a day 4 Restricting the client to her room until she has gained 2 lb

4 Restricting the client to her room until she gains 2 lb reinforces behaviors that will assist in the achievement of specific goals. Having the client role-play interactions with her parents is not part of a behavior modification program. Providing the client with a high-calorie, high-protein diet is not part of a behavior modification program. Anorexic clients talk freely about food; the problem is ingestion, not discussion.

A nurse is caring for a client who has abruptly stopped taking a barbiturate. What should the nurse anticipate that the client may experience? 1 Ataxia 2 Diarrhea 3 Urticaria 4 Seizures

4 Seizures are a serious side effect that may occur with abrupt withdrawal from barbiturates. The other options are not associated with barbiturate withdrawal.

A nurse encourages a client to attend Alcoholics Anonymous (AA) meetings after discharge. What do self-help groups such as AA help their members do? 1 Set long-term goals. 2 Limit excessive drinking. 3 Identify underlying causes of behavior. 4 Foster changes in behavior.

4 Self-help groups deal with behavior and changes in behavior rather than with underlying causes of behavior. Small steps are encouraged and, when attained, are reinforced by the group. AA is known for encouraging its members to deal with one day at a time. Abstinence, not controlled drinking, is the foundation for sobriety. Identifying underlying causes of behavior is not the purpose of self-help groups.

A client is prescribed sertraline (Zoloft), an antidepressant. What should the nurse include when preparing a teaching plan about the side effects of this drug? 1 Seizures 2 Tachycardia 3 Agranulocytosis 4 Agitation

4 Sertraline (Zoloft), a selective serotonin reuptake inhibitor (SSRI), inhibits neuronal uptake of serotonin in the central nervous system, thus potentiating the activity of serotonin. Central nervous system side effects of this drug include agitation, anxiety, confusion, dizziness, drowsiness, and headache. Seizures are a side effect of clozapine (Clozaril), an antipsychotic, not sertraline, which is an antidepressant. Tachycardia is a side effect of tricyclic antidepressants, not sertraline, which is an SSRI antidepressant. A decrease in the production of granulocytes (agranulocytosis) causing a pronounced neutropenia is a side effect of clozapine, not sertraline.

A nurse greets a client who has been experiencing delusions of persecution and auditory hallucinations by saying, "Good evening. How are you?" The client, who has been referring to himself as "the man," answers, "The man is bad." Of what is this an example? 1 Transference 2 Displacement 3 Identification 4 Dissociation

4 Speaking in the third person reflects poor ego boundaries and dissociation from the real self. Transference is the movement of emotional energy and feelings that one has for one person to another person. Displacement is an attempt to reduce anxiety by transferring the emotions associated with one object or person to another. Identification is an attempt to increase self-esteem by acquiring the attributes or characteristics of an admired individual.

During a group meeting a client tells everyone, "I'm about to be discharged from the hospital, and I'm afraid." What is the most appropriate response by the nurse facilitator? 1 "You ought to be happy that you're leaving." 2 "Maybe you're not ready to be discharged yet." 3 "How many in the group feel that this member is ready to be discharged?" 4 "Maybe others in the group have similar feelings that they would share."

4 Stating that others in the group have similar feelings permits the client to see that these feelings are not unique and are shared by others. Stating that the client should be happy about leaving will make the client worry about not feeling happy. Stating that the client may not be ready to be discharged is a nonsupportive response to a realistic fear of leaving the safe hospital and going back to the "real world," where problems must be confronted. How the others feel about whether the client is ready to be discharged is irrelevant.

A nurse is teaching a group of recently hired staff members about conscious and unconscious defense mechanisms that are used to defend the self against anxiety. What is an example of a conscious defense mechanism that the nurse should include? 1 Undoing 2 Projection 3 Intellectualization 4 Suppression

4 Suppression is a conscious measure used as a defense against anxiety; the affected person intentionally avoids thinking about disturbing problems, wishes, feelings, or experiences. Undoing is an unconscious defense mechanism; it is the use of words or behavior to make amends symbolically for unacceptable thoughts, feelings, or actions. Projection is an unconscious defense mechanism; it is the false attribution to others of one's own unacceptable impulses, feelings, attitudes, or thoughts. Intellectualization is an unconscious defense mechanism; it is the use of thinking, ideas, or intellect to avoid emotionally charged feelings.

A nurse is counseling a client who has had an angry episode that subsided after several minutes. What is the most important short-term objective for the client? 1 Continuing to vent angry feelings 2 Recognizing the ways in which anger hurts others 3 Requesting increased medication when feelings of anger occur 4 Talking about situations that cause angry outbursts

4 Talking about situations that precipitate anger is the first step in helping a client to cope with his feelings. Continuing to vent angry feelings is nonproductive; it may escalate the feelings of anger and result in aggressive behavior. The client, not others, should be the focus of short-term objectives. The client needs to learn acceptable ways of coping with positive and negative feelings. Medication does not help the client learn new ways of coping.

A physician is admitted to the psychiatric unit of a community hospital. The client, who was restless, loud, aggressive, and resistive during the admission procedure, announces, "I'll take my own blood pressure." What is the most therapeutic response by the nurse? 1 "Right now you're just another client." 2 "If you would rather, I'm sure you will do it correctly." 3 "I'll get the attendants to assist me if you won't cooperate." 4 "I'm sorry, but I can't allow that, because I have to take your blood pressure."

4 Telling the client that the nurse cannot allow him to take his own blood pressure simply states facts without getting involved in role conflict. Being a physician is a big part of this client's self-esteem, and telling him that he is just another client will threaten that self-esteem. Having the client take his own blood pressure will confuse the client's role on the unit. A client who is a physician cannot be responsible for checking vital signs. Threats will make the situation worse and set the tone for future negative nurse-client interactions.

A client is admitted to the psychiatric unit wearing evening clothes. During the first 24 hours the client paces continually and laughs loudly. When approached by the nurse, the client refuses to cooperate with any requests, shouting, "I'm in charge. I give the orders!" How does the nurse interpret this behavior? 1 It fulfills innate desires. 2 It appeases imagined isolation. 3 It controls the urge to relate to others. 4 It attempts to ward off depression

4 The client expends a great amount of energy running headlong into reality in an attempt to ward off or avoid facing feelings of depression. The behavior is not an expression of innate desires or an attempt to compensate for imagined isolation but instead is an attempt to avoid feelings of depression. The client has no difficulty relating to others.

A college student visits the health center and describes anxiety about having to declare an academic major. What developmental conflict, according to Erikson, is this client still attempting to resolve? 1 Initiative versus guilt 2 Integrity versus despair 3 Industry versus inferiority 4 Identity versus role confusion

4 The client is demonstrating a search for self and has not resolved the developmental conflict of adolescence, identity versus role confusion. Initiative versus guilt is the developmental conflict of early childhood. Integrity versus despair is the developmental conflict of old age. Industry versus inferiority is the developmental conflict of middle childhood.

An older adult living in a long-term care facility has been receiving lithium 600 mg twice a day for 3 weeks to ease manic behavior. The client is experiencing nausea and vomiting, diarrhea, thirst, polyuria, slurred speech, and muscle weakness. What is the most appropriate nursing intervention? 1 Obtaining a prescription for the antidote to lithium and administering it immediately 2 Suggesting that the practitioner replace the lithium for an antiepileptic that will control the mania 3 Assessing the client for coarse hand tremor and, if it is present, giving the daily dose of lithium with a bit of water 4 Withholding the next dose of lithium and drawing blood to test it for toxicity

4 The client is displaying signs and symptoms of early lithium toxicity; older clients should be monitored carefully and given smaller doses of lithium because its excretion from the kidneys is slower than that in younger adults. There is no antidote to lithium. Coarse hand tremor is an indication of advanced lithium toxicity; the lithium should be withheld. Although antiepileptics are effective in 25% to 50% of clients with treatment-resistant bipolar disorder, this is not the appropriate treatment for lithium toxicity.

A nurse recalls that in a conversion disorder, pseudoneurological symptoms such as paralysis or blindness: 1 Are unconscious methods of getting attention 2 Will subside if the client is helped to focus on getting healthy 3 Will usually resolve when the client learns to cope with ongoing family conflicts 4 Are generally necessary for the client to cope with a stressful situation

4 The client is experiencing a psychological conflict that is manifested by a change in body function. Paralysis or blindness is not an unconscious means of getting attention. Paralysis or blindness justifies the inability to move in any direction. It is an unconscious method of solving a conflict. It is necessary for the client to focus on the problem causing the disorder, not on the cure. It is more important that the client learn how to manage personal feelings before addressing family conflicts that may or may not exist.

An obviously upset client comes to the mental health clinic and, after pushing ahead of the other clients, states, "I had an argument with my daughter, and now I'm tense, and worried, and angry." What level of anxiety does the nurse determine that the client is experiencing? 1 Mild 2 Panic 3 Severe 4 Moderate

4 The client is focused on one part of reality but is unable to grasp the total picture; this situation reflects a moderate level of anxiety. Mild anxiety is the level at which the individual is cognizant of all aspects of reality but has a "jumpy feeling" and "butterflies in the stomach." Panic is the level at which the individual is no longer in contact with reality, is unable to make decisions, has impaired judgment, and is dysfunctional. Severe anxiety is the level at which individuals lose touch with reality and have a feeling of impending doom, which tends to immobilize them.

During the orientation tour for three new staff members, a young, hyperactive manic client greets them by saying, "Welcome to the funny farm. I'm Jo-Jo, the head yo-yo." Which meaning can the nurse assign to the client's statement? 1 Trying to fill the "life of the party" role 2 Looking for attention from the new staff 3 Unable to distinguish fantasy from reality 4 Anxious over the arrival of new staff members

4 The client's behavior demonstrates increased anxiety. Because it was directed toward the new staff, it was probably precipitated by their arrival. The client is not filling the "life of the party" role; the client is resorting to previous coping behavior in the face of extreme stress. It is possible that the client is looking for attention from the new staff, but the remark is more indicative of increased anxiety. The client is aware of what is going on and who everyone is at this time.

A 30-year-old female client asks the nurse to change her room, stating that she hates her roommate and can't stand to be in the same room with her. Just as she finishes speaking, her roommate enters and the client tells her she missed her and has been all over the unit looking for her. The nurse recognizes that the client is using: 1 Projection 2 Sublimation 3 Passive aggression 4 Reaction formation

4 The client's expressed feelings are opposite the client's behavior and are an acceptable substitute for repressed antisocial feelings when facing the roommate. The client's feelings are expressed to the nurse, not projected or attributed to others. The client has expressed real feelings to the nurse and has made no attempt to make an instinctual, socially unacceptable impulse into an acceptable behavior. The client has not masked covert hostility with overt compliance.

A client on the psychiatric unit who is receiving high-dosage risperidone (Risperdal) is exhibiting tremors of the hands. What should be the nurse's first intervention? 1 Withholding the medication 2 Telling the client it is transitory 3 Giving the client finger exercises 4 Contacting the health care provider

4 The health care provider is responsible for prescribing medications but depends on the nurse's observations before making decisions. This is not a severe enough finding to warrant withholding the drug. It is a reaction to the risperidone (Risperdal), and it is not transitory. Giving the client finger exercises will have no effect on the tremors.

What should a nurse recognize that a client who uses the defense mechanism of sublimation is doing? 1 Acting out in reverse something already done or thought 2 Returning to an earlier, less mature stage of development 3 Excluding from consciousness thoughts that are psychologically disturbing 4 Channeling unacceptable impulses into socially approved behavior

4 The individual using sublimation attempts to fulfill desires by selecting a socially acceptable activity rather than one that is socially unacceptable. Acting out in reverse something already done or thought is reaction formation. Returning to an earlier, less mature stage of development is regression. Excluding from consciousness thoughts that are psychologically disturbing is repression.

To provide appropriate psychosocial support to clients, a nurse must understand development across the life span. What theory is the nurse using in considering relationships and resulting behaviors the central factors that influence development? 1 Cognitive theory 2 Psychosocial theory 3 Psychosexual theory 4 Interpersonal theory

4 The interpersonal theory of human development by Harry Stack Sullivan highlights interpersonal behaviors and relationships as the central factors influencing child and adolescent development across six "eras"; the need to satisfy social attachments and a longing to meet biologic and psychological needs are two dimensions associated with this theory. Cognitive theory is associated with Jean Piaget; cognitive theory explains how thought processes develop, are structured, and influence behavior. Psychosocial theory is associated with Erik Erikson; psychosocial theory identifies social interaction as the source that influences human development. Erikson identified eight stages of human life, with each stage built on the previous stages and influenced by past experiences. Psychosexual theory is associated with Sigmund Freud; psychosexual theory views child development as a biologically driven series of conflicts and gratifying internal needs.

16. The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.) A) Permit rest periods as needed. B) Speaking slowly and simply. C) Place the client on suicide precautions. D) Allow the client extra time to complete tasks. E) Observe and encourage food and fluid intake. F) Encourage mild exercise and short walks on the unit

(A, B, D, E, and F) should be included in this client's plan of care because these measures promote the client's comfort and well-being. Neurovegetative symptoms accompany the mood disorder of depression and include physiological disruptions, such as anorexia, constipation, sleep disturbance, and psychomotor retardation. Suicidal ideation (C) does not usually accompany the neurovegetative state because the client does not have the energy or high level of anxiety associated with a suicide attempt. Correct Answer(s): A, B, D, E, F

68. Physical examination of a 6-year-old reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate? A) I need to inform the healthcare provider about your child's tendency to be accident prone. B) Tell me more specifically about your child's accidents. C) I must report these injuries to the authorities because they do not seem accidental. D) Boys this age always seem to require more supervision and can be quite accident prone.

(B) seeks more information using an open ended, non-threatening statement. (A) could be appropriate, but it is not the best answer because the nurse is being somewhat sarcastic and is also avoiding the situation by referring it to the healthcare provider for resolution. Although it is true that suspected cases of child abuse must be reported, (C) is virtually an attack and is jumping to conclusions before conclusive data has been obtained. (D) is a cliché and dismisses the seriousness of the situation. Correct Answer(s): B

The nurse should first discuss terminating the nurse-client relationship with a client during the: 1 Working phase, when the client initiates it 2 Orientation phase, when a contract is established 3 Working phase, when the client shows some progress 4 Termination phase, when discharge plans are being made

2 When the nurse and client agree to work together, a contract should be established, and the length of the relationship should be discussed in terms of its ultimate termination. The client may discuss termination during the working phase; however, the subject should initially be discussed during the orientation phase. Termination and discharge plans may be discussed more thoroughly during this phase, but the subject should initially be discussed during the orientation phase.

When talking with a client in crisis, the crisis intervention nurse should first: 1 Assist the client in deciding what will be done and how it will be done. 2 Identify problems for the client, putting them in the proper perspective. 3 Explain that the center has helped many clients with the same problem. 4 Explore the client's religious and cultural beliefs to ensure that interventions support the client's values

1 Although problem-solving potential is increased when clients are involved in exploring alternatives that will affect the direction of their own lives, clients in crisis may be overwhelmed and initially need assistance in making decisions. The client, not the crisis intervention practitioner, should identify the problem; the practitioner facilitates the process. Telling the client that the center has helped many similar clients is pointless because the client is unable to empathize with others at this time. Identifying the client's religious and cultural beliefs is not the priority at this time.

A client has been taking amoxapine (Asendin) for the past 3 months with no improvement. The practitioner prescribes phenelzine (Nardil) to be given as well. The nurse should: 1 Question the prescription and withhold the medication. 2 Ask the client about allergies to feathers before giving the first dose. 3 Withhold the medication until a specimen for liver enzymes is drawn. 4 Remind the client that this medication should be taken with meals and that milk products must be avoided.

1 Amoxapine (Asendin) is a tricyclic antidepressant (TCA), and phenelzine (Nardil) is a monoamine oxidase inhibitor (MAOI); TCAs are contraindicated in concomitant use with MAOIs. Although checking for allergies is important, an allergy to feathers is not specific to MAOIs. Blood tests are not done specifically before the administration of MAOIs. Phenelzine does not have to be taken with food. Milk products, with the exception of aged cheeses and yogurt, may be eaten; products containing tyramine must be avoided.

A nurse should base care for grieving clients on the knowledge that the grieving process may last longer for people who have: 1 Feelings of guilt 2 Ambivalent feelings about death 3 Failed to remarry after several years 4 Close relationships with family members

1 Guilt feelings can prolong the grieving process because the individual is overwhelmed by both guilt and grief and consequently the energy needed to cope with both is excessive. Ambivalent feelings about the deceased, not the death itself, can prolong grief. There are no research data to support the belief that the grieving process lasts longer for people who failed to remarry after several years. Usually the opposite is true; the support provided hastens the resolution of grief.

Donepezil (Aricept) is prescribed for a senior client who has mild dementia of the Alzheimer type. What information does the nurse include when discussing this medication with the client and family? 1 Fluids should be limited to four large glasses per day. 2 Constipation should be reported to the practitioner immediately. 3 Blood tests that reflect liver function will be performed routinely. 4 The client's medication dosage may be self-adjusted according to the client's response.

3 Donepezil may affect the liver because alanine aminotransferase (ALT) is found predominantly in the liver; most ALT increases indicate hepatocellular disease. Clients taking this medication should have regular liver function tests and report light stools and jaundice to the practitioner. Fluids should not be limited, because one of the side effects of donepezil (Aricept) is constipation. A side effect of constipation is expected; therefore fluids, high-fiber foods, and exercise should be recommended to help keep the stools soft . The client should not abruptly increase or decrease the dosage; donepezil should be taken exactly as prescribed.

Considering the anticholinergic-like side effects of many of the psychotropic drugs, the nurse should encourage clients taking these drugs to: 1 Restrict their fluid intake. 2 Eat a diet high in carbohydrates. 3 Suck on sugar-free hard candies. 4 Avoid products that contain aspirin.

3 Hard candy may produce salivation, which helps alleviate the anticholinergic-like side effect of dry mouth that is experienced with some psychotropics. Dry mouth increases the risk for cavities; candy with sugar adds to this risk. Fluids should be encouraged, not discouraged; fluids may alleviate the dry mouth. The other options are unnecessary.

When talking with a client who has alcoholism, the nurse notes that the client becomes irritable, makes excuses, and blames family and friends for the drinking problem. Which defense mechanisms does the nurse conclude that the client is using? Select all that apply. 1 Projection 2 Suppression 3 Sublimation 4 Identification 5 Rationalization

15 Projection is the unconscious denial of unacceptable feelings and emotions in one's self while attributing them to others. This defense mechanism commonly is used by clients with alcoholism because it helps make reality more acceptable. Rationalization is making acceptable excuses for behavior; this defense is used by people with alcoholism because it makes reality more acceptable. Suppression keeps uncomfortable thoughts, feelings, and wishes in the subconscious; suppression is used rarely by people with alcoholism. Sublimation (the rechanneling of anxiety into constructive activities) is rarely used by these clients. Identification is the unconscious wish to be like another person; it is not commonly used by clients with an alcohol problem.

The emergency department nurse is conducting an interview and assisting with the physical examination of a female sexual assault victim. What is most important for the nurse to document on this client's record? 1 Observations about the client's reaction to male staff members 2 Statements by the client about the sexual assault and the rapist 3 Information about the client's previous knowledge of the rapist 4 Summary statement about the client's description of the assault and the rapist

2

What should the nurse do when determining whether a client is experiencing adverse effects of risperidone (Risperdal)? 1 Monitor for episodes of diarrhea. 2 Test sensation of lower extremities. 3 Question if dizziness is experienced. 4 Auscultate breath sounds to detect wheezing.

3 Hypotension and dizziness are adverse effects of risperidone (Risperdal). Risperidone may cause constipation, not diarrhea. It does not affect the neuromuscular or cardiovascular function of the legs; numbness and coldness of the feet do not occur. Risperidone does not cause wheezing or shortness of breath.

n a mental health day treatment program, a psychiatric nurse is assessing a client's activity level. The client starts to walk swiftly around the room while rubbing the hands together. What should the nurse conclude that the client is exhibiting? 1 Tardive dyskinesia 2 Withdrawal syndrome 3 Psychomotor agitation 4 Psychophysiological insomnia

3 Psychomotor agitation is constant motion such as pacing, hand-wringing, nail-biting, and other types of energetic body movements. Tardive dyskinesia is a syndrome of involuntary movements (e.g., oral, buccal, lingual, masticatory) that occur as a result of prolonged treatment with neuroleptic drugs that block dopamine type 2 receptors. Withdrawal syndrome includes the signs and symptoms caused by the abrupt cessation of a substance that the client has become dependent on as a result of prolonged use. Psychophysiological insomnia refers to difficulty attaining or maintaining sleep; it is not related to agitated behavior.

What developmental task should the nurse consider when caring for toddlers? 1 Trust 2 Industry 3 Autonomy 4 Identification

3 Testing the self both physically and psychologically occurs during the toddler stage, after trust has been achieved. Trust is the task of infancy. The task of industry is accomplished between the ages of 6 and 12. Identification is not a developmental task. However, between the ages of 3 and 6 a child starts to identify with the parent of the same sex. trust, autonomy, industry

A nurse is caring for clients who are undergoing therapy for dependence on alcohol. Which member of the health team has the primary responsibility for their rehabilitation? 1 Nurse 2 Client 3 Counselor 4 Psychiatrist

2 According to the philosophy of Alcoholics Anonymous, clients who have problems with alcohol must identify their own need to seek help and therefore become the primary rehabilitators. The nurse can give support but is not the primary rehabilitator. The counselor can give direction but is not the primary rehabilitator. The psychiatrist can give support, but the client is the primary rehabilitator when it comes to coping with alcoholism.

A terminally ill client is moving gradually toward resolution of feelings about impending death. In a plan of care based on Elisabeth Kübler-Ross' research, the nurse should use nonverbal interventions after having assessed that the client is in the: 1 Anger stage 2 Denial stage 3 Bargaining stage 4 Acceptance stage

4 When acceptance is reached, the individual is beginning to withdraw from life; communication is simple, concise, and most often nonverbal. Kübler-Ross' research has shown that this stage usually requires verbal interventions and communication. The client has moved past the anger, denial, and bargaining stages.

A male long-distance jumper improves his distance by 3½ inches (7 cm) and earns the praise of his coach, but on another day, when he does not reach his mark, he forcefully kicks the door of his locker. What defense mechanism does his outburst demonstrate? 1 Anger 2 Projection 3 Displacement 4 Rationalization

3 Displacement is the discharging of pent-up feelings on a less threatening object, in this case the locker door. Anger is not a defense mechanism. Projection is attributing one's own unacceptable feelings, impulses, or thoughts to another. Rationalization is behavior that attempts to prove that one's feelings or behavior is justifiable.

A client asks the nurse, "Because I'm so comfortable talking with you, can we go out for coffee and movie after I get discharged?" To maintain the boundaries of a therapeutic relationship, how will the nurse respond? 1 "I'm flattered but that would be professionally unethical." 2 "You feel connected to me now; that will change once you are discharged." 3 "The attention I've giving you is directed towards getting you better; it isn't social." 4 "A social life is important so as your nurse let's talk about how you can form friendships."

4 Clients often become socially interested in the nursing staff. When this occurs the nurse should remind the client of the nursing role and take the opportunity to discuss the need for friendships and how to achieve them best. Stating "I'm flattered but that would be professionally unethical," "You feel connected to me now; that will change once you are discharged," and "The attention I've giving you is directed towards getting you better; it isn't social," while not untrue or inappropriate, do not address best the nursing responsibility in this therapeutic role.

A client with diabetes mellitus is able to discuss in detail the diabetic metabolic process while eating a piece of chocolate cake. What defense mechanism does the nurse identify when evaluating this behavior? 1 Projection 2 Dissociation 3 Displacement 4 Intellectualization

4 Intellectualization is the avoidance of a painful emotion with the use of a rational explanation that removes the event from any personal significance. Projection is the attribution of unacceptable thoughts and feelings to others. Dissociation is a temporary alteration of consciousness or identity used to handle conflict; amnesia is an example. Displacement is the discharge of a pent-up feeling, generally hostility, on an object or person perceived to be weaker than the person who aroused the feelings.

The wife of a client who is dying tells the nurse that although she wants to visit her husband daily, she can visit only twice a week because she works and has to take care of the house and their cat and dog. What defense mechanism does the nurse conclude that the client's wife is using? 1 Projection 2 Sublimation 3 Compensation 4 Rationalization

4Rationalization is offering a socially acceptable or logical explanation to justify an unacceptable feeling or behavior. Projection is the denial of emotionally unacceptable feelings and the attribution of the traits to another person. Sublimation is the substitution of a socially acceptable behavior for an unacceptable feeling or drive. Compensation is making up for a perceived deficiency by emphasizing another feature perceived as an asset.

59. The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug should the nurse expect this client to make? A) My mouth feels like cotton. B) That stuff gives me indigestion. C) This pill gives me diarrhea. D) My urine looks pink.

A dry mouth (A) is an anticholinergic effect that is an expected side effect of MAO inhibitors such as phenelzine sulfate (Nardil). (B, C, and D) are not expected side effects of this medication. Correct Answer(s): A

8. The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority? A) Excessive work activity. B) Decreased need for sleep. C) Medication management. D) Inflated self-esteem.

The most important nursing problem is medication management (C) because compliance with the medication regimen will help prevent hospitalization. The client is also exhibiting signs of (A, B, and C); however, these problems do not have the priority of medication management. Correct Answer(s): C

52. The nurse plans to help an 18-year-old female mentally retarded client ambulate the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, "Get out of here! I'll get up when I'm ready!" Which response is best for the nurse to make? A) Your healthcare provider has prescribed ambulation on the first postoperative day. B) You must ambulate to avoid complications which could cause more discomfort than ambulating. C) I know how you feel. You're angry about having to ambulate, but this will help you get well. D) I'll be back in 30 minutes to help you get out of bed and walk around the room.

(D) provides a "cooling off" period, is firm, direct, non-threatening, and avoids arguing with the client. (A) is avoiding responsibility by referring to the healthcare provider. (B) is trying to reason with a mentally retarded client and is threatening the client with "complications." (C) is telling the client how she feels (angry), and the nurse does not really "know" how this client feels, unless the nurse is mentally retarded and has just had an appendectomy! Correct Answer(s): D

48. The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions? A) The parents' explanation of how the burns occurred is different from the child's explanation of how they occurred. B) The parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed any problem. C) The parents become very anxious when the nurse suggests that the child may need to be admitted for further evaluation. D) The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.

(D) provides the most validation. The parent's explanation (subjective data) is incompatible with the objective data (small round burns on the legs and trunk). (A) provides only subjective data, and the child's explanation could be influenced by factors such as age, fear, or imagination. The parent's apparent lack of concern (B) is inconclusive, but the nurse's opinion of the parents' reaction is subjective and could be wrong. (C) might provide a clue that child abuse occurred, but the nurse must remember that most parents are anxious about their child being hospitalized. Correct Answer(s): D

A client who has been taking the prescribed dose of zolpidem (Ambien) for 5 days returns to the clinic for a follow-up visit. When interviewing the client, the nurse identifies that the medication has been effective when the client says: 1 "I have less pain." 2 "I have been sleeping better." 3 "My blood glucose is under control." 4 "My blood pressure is coming down."

2 Zolpidem (Ambien) is a sedative-hypnotic that produces central nervous system depression in the limbic, thalamic, and hypothalamic areas of the brain. Zolpidem is not an analgesic, antidiabetic, or antihypertensive medication.

An 18-year-old woman is brought to the emergency department by her two roommates after being found unconscious in the bathroom. Laboratory tests are ordered. The nurse reviewing the findings notes that the urinalysis is positive for flunitrazepam (Rohypnol). The nurse knows that flunitrazepam is often used: 1 As a date rape drug 2 To control symptoms of psychosis 3 To control symptoms of bipolar mania 4 To treat hangover symptoms after excessive alcohol consumption

1 Rohypnol (flunitrazepam), illegal in the United States, has been used in date rapes; the victim is attacked after consuming a drink spiked with the drug. Flunitrazepam is not used to treat psychosis, mania, or hangover symptoms

23. The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up? A) Menstruation onset at age 9. B) Contraceptive method includes condoms only. C) Menstrual cycle occurs every 35 days. D) Black-out after one drink last night on a date.

A "black-out" typically occurs after ingestion of alcohol beverages that the client has no recall of the experiences or one's behavior and is indicative of high blood alcohol levels, but the client's experience of a "black-out" after one drink (D) is suspicious of the client receiving a "date rape" drug (Flunitrazepam) and needs additional follow-up. Although (A and C) occur on the outer ranges of "average," both are within acceptable or "normal" ranges. (B) is an individual preference, but using condoms as the only contraceptive method carries a higher chance of conception. Correct Answer(s): D

62. A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying poison him. What intervention should the nurse include in this client's plan of care? A) Remind the client that his suspicions are not true. B) Ask one nurse to spend time with the client daily. C) Encourage the client to participate in group activities. D) Assign the client to a room closest to the activity room.

A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationship with one nurse (B) is likely to be therapeutic for this client. (A) is argumentative. Stress increases anxiety, and anxiety increases paranoid ideation; (C) would be too stressful and anxiety-promoting for a client who is experiencing pathological suspicions. (D) also might increase anxiety and stress. Correct Answer(s): B

63. The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)? A) Dizziness when standing. B) Shuffling gait and hand tremors. C) Urinary retention. D) Fever of 102° F.

A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. (A, B, and C) are all adverse effects of Haldol which can be managed. Correct Answer(s): D

A secretary in a home health agency gossips about coworkers and then writes them notes to tell them how valuable they are to the organization and how much she likes working with them. What defense mechanism is being used by the secretary? 1 Denial 2 Undoing 3 Displacement 4 Intellectualizatio

2 Undoing is atonement for or an attempt to dissipate unacceptable acts or wishes. Denial is the refusal to accept or perceive unpleasantness as it actually exists. Displacement is the discharge of pent-up feelings onto something or someone that is less threatening than the original source of the feelings. Intellectualization is the use of abstract thinking to minimize painful feelings.

30. A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the client's fear and anxiety, how should the nurse respond? A) "I would be very upset and mad if my best friend did that to me." B) "You must feel betrayed, but maybe you might have led him on?" C) "Rape is not limited to strangers and frequently occurs by someone who is known to the victim." D) "This does not sound like rape. Did you change your mind about having sex after the fact?"

A victim of date rape or acquaintance rape is less prone to recognize what is happening because the incident usually involves persons who know each other and the dynamics are different than rape by a stranger. (C) provides confrontation for the client's denial because the victim frequently knows and trusts the perpetrator. Nurses should not express personal feelings (A) when dealing with victims. Suggesting that the client led on the rapist (B) indicates that the sexual assault was somehow the victim's fault. (D) is judgmental and does not display compassion or establish trust between the nurse and the client. Correct Answer(s): C

18. Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate). What is most important to teach the client and family about this change in medication regimen? A) Signs and symptoms of extrapyramidal effects (EPS). B) Information about substance abuse and schizophrenia. C) The effects of alcohol and drug interaction. D) The availability of support groups for those with dual diagnoses.

Alcohol enhances the EPS side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2 to 4 weeks. That means the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long-acting Prolixin Decanoate IM. (A, B, and D) provide valuable information and should be included in the client/family teaching, but they do not have the priority of (C). Correct Answer(s): C

28. A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take? A) Encourage the client's participation in unit activities by asking her to pass trays for the rest of the week. B) Provide an additional challenge by asking the client to also help feed the older clients. C) Suggest another way for this client to participate in unit activities. D) Tell the client that hospital policy does not permit her to pass trays.

Anorexics gain pleasure from providing others with food and watching them eat. Such behaviors reinforce their perception of self-control. These clients should not be allowed to plan or prepare food for unit activities and their desires to do so should be redirected (C). (A and B) are contraindicated for a client with anorexia nervosa. (D) avoids addressing the problem and is manipulative in that the nurse is blaming hospital policy for treatment protocol. Correct Answer(s): C

11. At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the leader." What is the best response for the nurse to make? A) Yes, I am the leader today. Would you like to be the leader tomorrow? B) Yes, I will be leading this group. What would you like to accomplish during this time? C) Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks. D) Yes, I am the leader. You seem angry about not being the leader yourself.

Anxiety over participation in a group and testing of the leader characteristically occur in the initial phase of group dynamics. (B) provides information and focuses the group back to defining its function. (A) is manipulative bargaining. Although (C) provides information, it does not focus the group on its purpose or task. (D) is interpreting the client's feelings and is almost challenging. Correct Answer(s): B

60. A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage? A) He ingested the drug 3 hours prior to admission to the emergency center. B) The family reports that he took an entire bottle of acetaminophen (Tylenol). C) He is unresponsive to instructions and is unable to cooperate with emetic therapy. D) Those with repeated suicide attempts desire punishment to relieve their guilt.

Because the client is unable to follow instructions, emetic therapy would be very difficult to implement and gastric lavage would be necessary (C). (A and B) should be considered in determining the course of treatment, but they are not the basis for determining if gastric lavage will be implemented. Medical treatments should never be used as "punitive" measures (D). Correct Answer(s): C

74. A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with schizophrenia? A) Mood swings. B) Extreme sadness. C) Manipulative behavior. D) Flat affect.

Disinterest, and diminished or lack of facial expression is characteristic of schizophrenia and is referred to as a flat affect (D). (A) is associated with bipolar disorder. (B) is associated with depression. (C) is usually associated with personality disorders and is often seen in clients who abuse substances. Correct Answer(s): D

19. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide? A) You are in the hospital, and I am the nurse caring for you. B) It must be difficult for you to control your anxious feelings. C) Go to occupational therapy and start a project. D) You are not in a war area now; this is the United States.

Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others (C). Delusions are often well-fixed, and though (A) reinforces reality, it is argumentative and dismisses the client's fears. It is often difficult for the client to recognize the relationship between delusions and anxiety (B), and the nurse should reassure the client that he is in a safe place. Dismissing delusional thinking (D) is unrealistic because neurochemical imbalances that cause positive symptoms of schizophrenia require antipsychotic drug therapy. Correct Answer(s): C

40. A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? (Select all that apply.) A) Compulsions relieve anxiety. B) Anxiety is the key reason for OCD. C) Obsessions cause compulsions. D) Obsessive thoughts are linked to levels of neurochemicals. E) Antidepressant medications increase serotonin levels.

Correct choices are (A, B, D, and E). To promote client understanding and compliance, the teaching plan should include explanations about the origin and treatment options of OCD symptomology. Compulsions are behaviors that help relieve anxiety (A), which is a vague feeling related to unknown fears, that motivate behavior (B) to help the client cope and feel secure. All obsessions (C) do not result in compulsive behavior. OCD is supported by the neurophysiology theory, which attributes a diminished level of neurochemicals (D), particularly serotonin, and responds to selective serotonin reuptake inhibitors (SSRI). Correct Answer(s): A, B, D, E

55. A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first? A) Do you have problems with hallucinations? B) Are you ever alone when you hear the voices? C) Has anyone in your family had hearing problems? D) Do you see things that others cannot see?

Determining if the client is alone when she hears voices (B) will assist in differentiating between hallucinations and hearing loss; this is especially important in the aging population. If the client is experiencing hallucinations, the voices will be real to her, and it is unlikely that (A) would provide accurate information. (C and D) might be good follow-up questions, but would not have the priority of (B). Correct Answer(s): B

58. The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing intervention bests helps this client deal with his depression? A) Ensure that the client's day is filled with group activities. B) Assist the client in exploring feelings of shame, anger, and guilt. C) Allow the client to initiate and determine activities of daily living. D) Encourage the client to explore the rationale for his depression.

Depression is associated with feelings of shame, anger, and guilt. Exploring such feelings is an important nursing intervention for the depressed client (B). If the client's day is filled with group activities (A) he might not have the opportunity to explore these feelings. (C) is a good intervention for the chronically depressed client who exhibits vegetative signs of depression. (D) is essentially asking the client "why" he is depressed--avoid "why's" disguised as "rationale." Correct Answer(s): B

71. A client with bipolar disorder on the mental health unit becomes loud, and shouts at one of the nurses, "You fat tub of lard! Get something done around here!" What is the best initial action for the nurse to take? A) Have the orderly escort the client to his room. B) Tell the client his healthcare provider will be notified if he continues to be verbally abusive. C) Redirect the client's energy by asking him to tidy the recreation room. D) Call the healthcare provider to obtain a prescription for a sedative.

Distracting the client, or redirecting his energy (C), prevents further escalation of the inappropriate behavior. (A) could result in escalating the abuse and unnecessarily involve another staff member in the abusive situation. (B) is a threat and is using a health team member (healthcare provider) as the threat. (D) may be indicated if the behavior escalates, but, at this time, the best initial action is (C). Correct Answer(s): C

44. A 35-year-old male client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal his clothing. Which action should the nurse implement? A) Encourage the client to actively participate in assigned activities on the unit. B) Place a lock on the client's closet. C) Ignore the client's paranoid ideation to extinguish these behaviors. D) Explain to the client that his suspicions are false.

Diverting the client's attention from paranoid ideation and encouraging him to complete assignments can be helpful in assisting him to develop a positive self-image (A). The client's problem is not security, and (B) actually supports his paranoid ideation. (C) is not correct because ignoring the client's symptoms may lower his self-esteem. The nurse should not argue with the client about his delusions (D), and should not try to reason with the client regarding his paranoid ideation. Correct Answer(s): A

33. Which statement about contemporary mental health nursing practice is accurate? A) There is one approved theoretical framework for psychiatric nursing practice. B) Psychiatric nursing has yet to be recognized as a core mental health discipline. C) Contemporary practice of psychiatric nursing is primarily focused on inpatient care. D) The psychiatric nursing client may be an individual, family, group, organization, or community.

Mental health nursing is not only concerned with one-on-one interactions. Psychiatric stressors can impact and be reflected in the overall direction, activities, and responses involving families, groups, and entire communities (D). (A, B, and C) are incorrect statements about the status of mental health nursing. Correct Answer(s): D

38. The nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic? A) Loss of independence. B) Increased self-understanding. C) Isolation from society. D) Development of intimate relationships.

Middle adulthood is characterized by self-reflection, understanding, and acceptance (B), and generativity or guidance of children. (A and C) are maladaptive behaviors in middle adulthood. Although middle-aged adults may delay or re-establish intimate relationships, (D) is initially developed during young adulthood. Correct Answer(s): B

53. A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression? A) Grandiose ideation. B) Self-destructive thoughts. C) Suspiciousness of others. D) A negative view of self and the future.

Negative self-image and feelings of hopelessness about the future (D) are specific indicators for depression. (A and/or C) occurs with paranoia or paranoid ideation. (B) may be seen in depressed clients, but are not always present, so (D) is a better answer than (B). Correct Answer(s): D

6. The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents? A) If he has seemed depressed recently. B) If a drug overdose has ever occurred before. C) If he might have taken any other drugs. D) If he has a desire to quit taking drugs.

Knowledge of all substances taken (C) will guide further treatment, such as administration of antagonists, so obtaining this information has the highest priority. (A and B) are also valuable in planning treatment. (D) is not appropriate during the acute management of a drug overdose. Correct Answer(s): C

56. When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), it is most important for the nurse to include which instruction? A) It may take 3 to 4 weeks to achieve therapeutic effects. B) Keep your dietary salt intake consistent. C) Avoid eating aged cheese and chicken liver. D) Eat foods high in fiber such as whole grain breads.

Lithium's effectiveness is influenced by salt intake (B). Too much salt causes more lithium to be excreted, thereby decreasing the effectiveness of the drug. Too little salt causes less lithium to be excreted, potentially resulting in toxicity. (A, C, and D) are not specific instructions pertinent to teaching about lithium carbonate (Lithonate). Correct Answer(s): B

35. A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, "No, it's not MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to take? A) Reassure the client by telling him that his fear of the admission procedure is to be expected. B) Tell the client that no one is accusing him of murder and remind him that the hospital is a safe place. C) Assess the content of the hallucinations by asking the client what he is hearing. D) Ignore the behavior and make no response at all to his delusional statements.

Further assessment is indicated (C). The nurse should obtain information about what the client believes the voices are telling him--they may be telling him to kill the nurse! (A) is telling the client how he feels (fearful). The nurse should leave communications open and seek more information. (B) is arguing with the client's delusion, and the nurse should never argue with a client's hallucinations or delusions, also (B) is possibly offering false reassurance. (D) is avoiding the situation and the client's needs. Correct Answer(s): C

27. A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider? A) Decreased thyroid stimulating hormone level. B) Elevated liver function profile. C) Increased white blood cell count. D) Decreased hematocrit and hemoglobin levels.

Hyperthyroidism causes an increased level of serum thyroid hormones (T3 and T4), which inhibit the release of TSH (A), so the client's manic behavior may be related to an endocrine disorder. (B, C, and D) are abnormal findings that are commonly found in the homeless population because of poor sanitation, poor nutrition, and the prevalence of substance abuse. Correct Answer(s): A

29. A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client? A) Let me call and leave a message for your healthcare provider. B) The healthcare provider should be here on Monday morning. C) How can I help answer your questions? D) What concerns do you have at this time?

It is best for the nurse to call the healthcare provider (A) because clients have the right to information about their treatment. Suggesting that the healthcare provider will be available the following day (B) does not provide immediate reassurance to the client. The nurse can also implement offer to assist the client (C and D), but the highest priority intervention is contacting the healthcare provider. Correct Answer(s): A

17. An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the nurse to provide? A) Anywhere you want to stand as long as you do not get hurt by those in the parade. B) You are confused because of all the activity in the hall. There is no parade. C) Let us go back to the activity room and see what is going on in there. D) Remember I told you that this is a nursing home and I am your nurse.

It is common for those with Alzheimer's disease to use the wrong words. Redirecting the client (using an accepting non-judgmental dialogue) to a safer place and familiar activities (C) is most helpful because clients experience short-term memory loss. (A) dismisses the client's attempt to find order and does not help her relate to her surroundings. (B) dismisses the client and may increase her anxiety level because it merely labels the client's behavior and offers no solution. It is very frustrating for those with Alzheimer's disease to "remember," and scolding them (D) may hurt their feelings. Correct Answer(s): C

10. The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, "Yes, my love, I'll do it." When the nurse questions the client about her comment she states, "The news commentator is my lover and he speaks to me each evening. Only I can understand what he says." What is the best response for the nurse to make? A) What do you believe the news commentator said to you? B) Let's watch news on a different television channel. C) Does the news commentator have plans to harm you or others? D) The news commentator is not talking to you.

It is imperative that the nurse determine what the client believes she heard (A). The idea of reference may be to hurt herself or someone else, and the main function of a psychiatric nurse is to maintain safety. (B) is acceptable, but it is best to determine the client's beliefs. (C) is validating the idea of reference, while (D) is challenging the client. Correct Answer(s): A

67. A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? A) The nurse should obtain objective data such as x-rays before reporting suspicions to the authorities. B) The nurse should confirm any suspicions of child abuse with the healthcare provider before reporting to the authorities. C) The nurse should report any case of suspected child abuse to the nurse in charge. D) The nurse should note in the client's record any suspicions of child abuse so that a history of such suspicions can be tracked.

It is the nurse's legal responsibility to report all suspected cases of child abuse. Notifying the charge nurse starts the legal reporting process (C). Correct Answer(s): C

13. Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen? A) Hamburger, French fries, and chocolate milkshake. B) Liver and onions, broccoli, and decaffeinated coffee. C) Pepperoni and cheese pizza, tossed salad, and a soft drink. D) Roast beef, baked potato with butter, and iced tea.

Only (D) contains no tyramine. Tyramine in foods interacts with MAOI in the body causing a hypertensive crisis which is life-threatening, and Parnate is classified as an MAOI antidepressant. Some items in (A, B, and C) contain tyramine and would not be permitted for a client taking Parnate. Correct Answer(s): D

1. A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching? A) When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection. B) While I am on vacation and when I return, I will not eat or drink anything that contains alcohol. C) I will notify the healthcare provider if I have a sore throat or flu-like symptoms. D) I will continue to take my benztropine mesylate (Cogentin) every day.

Photosensitivity is a side effect of Prolixin and a vacation in the Bahamas (with its tropical island climate) increases the client's chance of experiencing this side effect. He should be instructed to avoid direct sun (A) and wear sunscreen. (B, C, and D) indicate accurate knowledge. Alcohol acts synergistically with Prolixin (B). (C) lists signs of agranulocytosis, which is also a side effect of Prolixin. In order to avoid extrapyramidal symptoms (EPS), anticholinergic drugs, such as Cogentin, are often prescribed prophylactically with Prolixin. Correct Answer(s): A

51. A 35-year-old male client on the psychiatric ward of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his A) early childhood experiences involving authority issues. B) anger about being hospitalized. C) low self-esteem. D) phobic fear of food.

Psychotic clients have difficulty with trust and have low self-esteem (C). Nursing care should be directed at building trust and promoting positive self-esteem. Activities with limited concentration and no competition should be encouraged in order to build self-esteem. (A, B, and D) are not specifically related to the development of delusions. Correct Answer(s): C

49. The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history upon admission to the hospital? A) Determine if the client attends a support group weekly. B) Hold all antidepressant medications until further notice. C) Ask the client if he takes St. John's Wort routinely. D) Have the client describe any recent changes in mood.

St. John's Wort, an herbal preparation, is an alternative (nonconventional) therapy for depression, but it may adversely interact with medications used to treat HIV infection (C). The nurse's top priority upon admission is to determine if the client has been taking this herb concurrently with HIV antiviral drugs, which may explain the rise in the viral load. Asking about (A or D) may be helpful in gathering more data about the client's depressive state, but these issues do not have the priority of (C). (B) may be harmful to the client. Correct Answer(s): C

69. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? A) Client will not demonstrate cross-addiction. B) Co-dependent behaviors will be decreased. C) Excessive CNS stimulation will be reduced. D) Client's level of consciousness will increase.

Substitution therapy with another CNS depressant is intended to decrease the excessive CNS stimulation that can occur during benzodiazepine withdrawal (C). (A, B, and D) are all appropriate outcome statements for the client described, but do not have the priority of (C). Correct Answer(s): C

12. The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning? A) Ineffective denial related to situational anxiety. B) Ineffective coping related to inadequate support. C) Social isolation related to difficult interactions. D) Self-care deficit related to cognitive impairment.

The best nursing diagnosis is (A) because the client is unable to acknowledge the move to a boarding home. (B, C, and D) are potential nursing diagnoses, but denial is most important because it is a defense mechanism that keeps the client from dealing with his feelings about living arrangements. Correct Answer(s): A

31. A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response? A) Can your case manager take you to your appointments? B) Take your medication for anxiety before you ride the bus. C) Let's talk about what happens when you feel very anxious. D) What are some ways that you can cope with your anxiety?

The best response is to explore ways for the client to cope with anxiety (D). The nurse should encourage problem-solving rather than dependence on the case manager (A) for transportation. Strategies for coping with anxiety should be encouraged before suggesting (B). (C) is therapeutic, but the best response is an open-ended question to explore ways to cope with the anxiety. Correct Answer(s): D

22. A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first? A) The emergency room nurse. B) His case manager. C) The clinic healthcare provider. D) His support group sponsor.

The case manager (B) is responsible for coordinating community services, and since this client has a dual diagnosis, this is the best person to describe available treatment options. (A) is unnecessary, unless the client experiences behaviors that threaten his safety or the safety of others. (C and D) might also be useful, but it is most important at this time that a treatment program be coordinated to meet this client's needs. Correct Answer(s): B

26. The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's behavior and thought processes are consistent with which syndrome? A) Dementia. B) Depression. C) Schizophrenia. D) Chronic brain syndrome.

The client is demonstrating symptoms of schizophrenia (C), such as disorganized speech that may include word salad (communication that includes both real and imaginary words in no logical order), incoherent speech, and clanging (rhyming). Dementia (A) is a global impairment of intellectual (cognitive) functions that may be progressive, such as Alzheimer's or organic brain syndrome (D). Depression (C) is typified by psychomotor retardation, and the client appears to be slowed down in movement, in speech, and would appear listless and disheveled. Correct Answer(s): C

34. A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time? A) Isolation. B) Stagnation. C) Despair. D) Role confusion.

The client is in Erikson's "Generativity vs. Stagnation" stage (age 24 to 45), and meeting the task includes maintaining intimate relationships and moving toward developing a family (B). (A) occurs in young adulthood (age 18 to 25), (C) occurs in maturity (age 45 to death), and (D) occurs in adolescence (age 12 to 20). These are all stages that occur if individuals are not successfully coping with their psychosocial developmental stage. Correct Answer(s): B

25. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach should the nurse use? A) Call a staff member to escort the client to his room. B) Tell the client to talk to his healthcare provider about his privileges. C) Remind the client of the unit rules. D) Ignore the client's inappropriate behavior.

The client is trying to engage the nurse in a dispute. Ignoring the behavior (D) provides no reinforcement for the inappropriate behavior. (A) is not necessary unless the client becomes a physical threat to the nurse. (B) would be inappropriate, because it is referring the situation to the healthcare provider and is not in keeping with good health team management. Consistent limits must be established and enforced. (C) would subject the nurse to more verbal abuse because the client could use any response as an excuse to attack the nurse once again. Correct Answer(s): D

73. A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change and the nurse formulates the diagnosis, "Confusion related to ICU psychosis." Which intervention is best to implement? A) Move all machines away from the client's immediate area. B) Attempt to allay the client's fears by explaining the etiology of his condition. C) Cluster care so that brief periods of rest can be scheduled during the day. D) Extend visitation times for family and friends.

The critical care environment confronts clients with an environment which provides stressors heightened by treatment modalities that may prove to be lifesaving. These stressors can result in isolation and confusion. The best intervention is to provide the client with rest periods (C). (A) is not practical--the machinery is often lifesaving. The client is not ready for (B). Although family and friends (D) can provide a support system to the client, visits should be limited because of the critical care that must be provided. Correct Answer(s): C

66. The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge? A) Crickets are a good source of protein. B) I have not heard any voices for a week. C) Only my belief in God can help me. D) Sometimes I have a hard time sitting still.

The most frequent cause of increased symptoms in psychotic clients is non-compliance with the medication regimen. If clients believe that "God alone" is going to heal them (C), then they may discontinue their medication, so (C) would pose the greatest threat to this client's prognosis. (A) would require further teaching, but is not as significant a statement as (C). (B) indicates an improvement in the client's condition. (D) may be a sign of anxiety that could improve with treatment, but does not have the priority of (C). Correct Answer(s): C

41. A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care? A) Reassure the client that no one will harm her while she is in the hospital. B) Ask the healthcare provider to give the client the medication. C) Explain that the diabetic medication is important to take. D) Reassess client's mental status for thought processes and content.

The most important intervention is to reassess the client's mental status (D) and to take further action based on the findings of this assessment. Attempting to reassure the client (A) is in effect arguing with the client's delusions and could escalate an already anxious situation. Collaborating about diabetic care (B and C) is not likely to help change the client's false beliefs. Correct Answer(s): D

2. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100° F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis? A) Risk for injury related to suicidal ideation. B) Risk for injury related to alcohol detoxification. C) Knowledge deficit related to ineffective coping. D) Health seeking behaviors related to personal crisis.

The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety related to (A) should be addressed after giving the client Ativan for elevated vital signs secondary to alcohol withdrawal. (C and D) can be addressed when immediate needs for safety are met. Correct Answer(s): B

3. The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit? A) Monitor appetite and observe intake at meals. B) Maintain safety in the client's milieu. C) Provide ongoing, supportive contact. D) Encourage participation in activities.

The most important reason for closely observing a depressed client immediately after admission is to maintain safety (B), since suicide is a risk with depression. (A, C, and D) are all important interventions, but safety is the priority. Correct Answer(s): B

7. The wife of a male client recently diagnosed with schizophrenia asks the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is best for the nurse to provide to this family member? A) It sounds like you're worried about your husband. Let's sit down and talk. B) It is a chemical imbalance in the brain that causes disorganized thinking. C) Your husband will be just fine if he takes his medications regularly. D) I think you should talk to your husband's psychologist about this question.

The nurse should answer the client's question with factual information and explain that schizophrenia is a chemical imbalance in the brain (B). (A) is a therapeutic response but does not answer the question, and may be an appropriate response after the nurse answers the question asked. Although (C) is likely true to some degree, it is also true that some clients continue to have disorganized thinking even with antipsychotic medications. Referring the spouse to the psychologist (D) is avoiding the issue; the nurse can and should answer the question. Correct Answer(s): B

45. A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." The nurse should initiate a referral based on which assessment? A) Altered thought processes. B) Moderate levels of anxiety. C) Inadequate social support. D) Altered health maintenance.

The nurse should initiate a referral based on anxiety levels (B) and feelings of nervousness that interfere with sleep, appetite, and the inability to solve problems. The client does not report symptoms of (A) or evidence of (C). There is not enough information to initiate a referral based on (D). Correct Answer(s): B

20. A male client with schizophrenia tells the nurse that the voices he hears are saying, "You must kill yourself." To assist the client in coping with these thoughts, which response is best for the nurse to provide? A) Tell yourself that the voices are unreasonable. B) Exercise when you hear the voices. C) Talk to someone when you hear the voices. D) The voices aren't real, so ignore them.

The nurse should teach the client to use self-talk to disprove the voices (A). Although (B) may be helpful, the client's concrete thinking may make it difficult to understand this suggestion. Clients with schizophrenia have difficulty initiating interaction with others (C). Auditory hallucinations are often relentless, so it is difficult to ignore them (D). Correct Answer(s): A

9. At a support meeting of parents of a teenager with polysubstance dependency, a parent states, "Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide." The nurse's response should be based on which information? A) Addiction is a chronic, incurable disease. B) Tolerance to the effects of drugs causes feelings of depression. C) Feelings of depression frequently lead to drug abuse and addiction. D) Careful monitoring should be provided during withdrawal from the drugs.

The priority is to teach the parents that their son will need monitoring and support during withdrawal (D) to ensure that he does not attempt suicide. Although (A and C) are true, they are not as relevant to the parent's expressed concern. There is no information to support (B). Correct Answer(s): D

47. An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client? A) Plan an outing within the first week of admission. B) Distract her whenever she expresses her discomfort about being with others. C) Confront her fears and discuss the possible causes of these fears. D) Accompany her outside for an increasing amount of time each day.

The process of gradual desensitization by controlled exposure to the situation which is feared (D), is the treatment of choice in phobic reactions. (A and C) are far too aggressive for the initial treatment period and could even be considered hostile. (B) promotes denial of the problem, and gives the client the message that discussion of the phobia is not permitted. Correct Answer(s): D

61. A 46-year-old female client has been on antipsychotic neuroleptics for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action should the nurse initiate? A) Place the client on seizure precautions and monitor carefully. B) Immediately transfer the client to ICU. C) Describe the symptoms to the charge nurse and record on the client's chart. D) No action is required at this time as these are known side effects of such drugs.

These symptoms are descriptive of neuroleptic malignant syndrome (NMS) which is an extremely serious/life threatening reaction to neuroleptic drugs (B). The major symptoms of this syndrome are fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can result in death. This is an EMERGENCY situation, and the client requires immediate critical care. Seizure precautions (A) are not indicated in this situation. (C and D) do not consider the seriousness of the situation. Correct Answer(s): B

43. A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the nurse to include in the client's plan of care? The client will A) outline methods for managing anger. B) control impulsive actions toward self and others. C) verbalize feelings when anger occurs. D) recognize consequences for behaviors exhibited.

Those with bipolar disorder often exhibit poor impulse control, and the most important goal for this client at this time is to learn to control impulsive behavior (B) so that he can avert the social consequences related to such behaviors. (A, C, and D) are important goals, but they do not address the acute issue of impulse control, which is necessary to reduce the likelihood of harming self or others. Correct Answer(s): B

14. An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide? A) Orient the client to the time, place, and person. B) Tell the client that the nurse is there and will help her. C) Remind the client that her mother is no longer living. D) Explain the seriousness of her injury and need for hospitalization.

Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of "offering self" and "talking to the feelings" to provide reassurance (B). Clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information, so (A, C, and D) are likely to be of little use to this client and do not help the client's emotional needs. Correct Answer(s): B