Psychiatric/Mental Health Nursing - Psychobiological Disorders
Which client characteristic is an initial concern for the nurse when caring for a client with the diagnosis of paranoid schizophrenia?
Suspicious feelings
A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of bingeing. Which clinical manifestation is most important for the nurse to evaluate?
Dehydration
A depressed client has feelings of failure and a low self-esteem. In what activity should the client initially be encouraged to become involved?
Assisting a staff member in working on the monthly bulletin board
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.)
Multiple losses Declines in health
What should the nurse do when interacting with an adolescent client with the diagnosis of anorexia nervosa?
Set limits
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?
"Around 2:30 in the afternoon is the best time to visit."
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.
"Hearing voices must be frightening "The voices you hear are part of your illness. "I don't hear any voices.' "Come with me for a walk.' "Let's play cards with another client in the recreation room."
A client with the diagnosis of schizophrenia, paranoid type, is admitted to the hospital. The client says to the nurse, "I know they're spying on me in here, too. I'm not safe anywhere!" What is the most therapeutic response by the nurse?
"You don't feel safe anywhere, not even in the hospital?"
A depressed client tells a nurse, "I want to die." What is the most therapeutic response by the nurse?
"You would rather not live."
A client is found to have paranoid schizophrenia, and the practitioner prescribes a typical antipsychotic medication. After a 1-month hospitalization the client is discharged home with instructions to continue the antipsychotic and a referral for weekly mental health counseling. The picture illustrates the client's physical status as observed by the nurse on the client's first visit to the community mental health clinic. What extrapyramidal side effect has developed?
Akathisia
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?
Anxious over the arrival of new staff members
A client is admitted to the psychiatric unit of the hospital with a diagnosis of conversion disorder. The client is unable to move either leg. Which finding should the nurse consider consistent with this diagnosis?
Appearing composed
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?
Attends Alcoholics Anonymous meetings dail
An older resident in a nursing home who has a diagnosis of dementia hoards leftover food from the meal tray and other seemingly valueless articles and stuffs them into pockets "so the others won't steal them." What should the nurse plan to do?
Give the resident a small bag in which to place selected personal articles and food
At mealtime a client with schizophrenia moves to the counter to choose food but is unable to decide what to do next. The nurse, recognizing the client's ambivalence, assists by using:
Simple declarative statements
A client tells the nurse, "I used to believe that I was a princess, but now I know that that's not true." What is the best response by the nurse?
That's is a sign that you're getting better.
One morning a female client with the diagnosis of schizophrenia tells the nurse that she is Joan of Arc and is going to be burned at the stake. What is the most therapeutic response by the nurse?
"It seems like the world is a pretty scary place for you."
A client tells the nurse, "A man is speaking to me from the corner of the room. Can you hear him?" How should the nurse respond?
"No, I don't hear him, but is it making you uncomfortable to hear him?"
A nurse is caring for a client who has been experiencing delusions. According to psychodynamic theory, delusions are
A defense against anxiety
A 5-foot 5-inch 15-year-old girl who weighs 80 lb is admitted to a mental health facility with a diagnosis of anorexia nervosa. The nurse recognizes that her problem most likely is caused by:
A desire to control her life
A nurse is caring for a group of depressed clients. What should the nurse attempt to provide?
An uncomplicated daily schedule
How should a nurse expect a client's anxiety to be manifested physiologically?
ncreased blood glucose level
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?
"Everyone is responsible for his own actions."
A client is admitted to the surgical unit with superficial wounds of both wrists, the result of a suicide attempt. When the nurse enters the room, the client says, "I suppose you're going to ask me about my suicide attempt." What is the best response by the nurse?
"Tell me how you feel about it."
A disturbed male client, unprovoked, attacks another client. A short-term initial plan for this client should include:
Having the client sit with a staff member in whom he trusts
A nurse is caring for a young, hyperactive child with attention deficit-hyperactivity disorder who engages in self-destructive behavior. What is the most important nursing objective in the planning of care for this child?
Keeping the child from inflicting any self-injury
A nurse knows individuals who are alcoholics use alcohol to:
Blunt reality
The nurse is working with a client who talks freely about feeling depressed. During the interaction the client states, "Things will never change." What findings support the nurse's conclusion that the client is experiencing hopelessness? (Select all that apply.)
Bouts of crying Self-destructive acts Feelings of worthlessness
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?
By reminding the nurse that once the content is known, there is no need to focus on the hallucinations because doing so reinforces them
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?
Constricted pupils
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:
Demonstration of respect for the rights of others
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.)
Denial Confusion Helplessness
A 6-year-old child recently started school but has been refusing to go for the past 3 weeks. The nurse determines that an appropriate intervention for this child is to:
Develop a behavior modification program with the child
A nurse is caring for a newly admitted, extremely depressed client. The most appropriate initial goal for the client
Developing trust in others
A nurse is caring for a client with vascular dementia. What does the nurse expect of this client's mental status?
Difficulty recalling recent events related to cerebral hypoxia
A client who is in a manic phase of bipolar disorder threatens staff and clients on a psychiatric acute care unit. Place the following interventions in priority order, from the least to the most restrictive.
Diversional activities Limit-setting Medication administration Seclusion Restraints
A nurse knows that children with attention deficit-hyperactivity disorder (ADHD) may be learning disabled. This means that these children:
Experience perceptual difficulties that interfere with learning
Risk for assaultive behavior is highest in the mental health client who:
Experiences command hallucinations
Which feelings should a nurse anticipate a client with bulimia nervosa to report experiencing during an episode of binge eating? (Select all that apply.)
Hopelessness Powerlessness
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?
Identity versus role confusion
A young client is admitted to the hospital with a diagnosis of acute schizophrenia. The family reports that one day the client looked at a linen sheet on a clothesline and thought it was a ghost. What is the most appropriate conclusion to make about what the client was experiencing?
Illusion
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?
Intramuscular injections of thiamine
A client is admitted to a mental health facility for depression. What action should a nurse take to help the client develop a positive self-regard?
Involve the client in activities that promote success
Why is observation an especially important aspect of nursing care for a withdrawn client?
It helps the nurse understand the client's behavior
A client with a history of depression tells the nurse about planning to retire from work next year. What common dynamic about retirement should the nurse consider when interacting with this client?
It is a developmental task of significance
A nurse determines that a client is pretending to be ill. What does this behavior usually indicate?
Malingering
What is the priority nursing intervention for a forgetful, disoriented client with the diagnosis of dementia of the Alzheimer type?
Managing the client's unsafe behaviors
A child with attention deficit-hyperactivity disorder (ADHD) often becomes frustrated and loses control. A nurse uses a variety of graduated techniques to manage disruptive behaviors. List the following interventions in order, from the least invasive to the most invasive.
Monitoring behavior for cues of rising anxiety Using a signal to remind the child to use self-control Avoiding situations that usually precipitate frustration Refocusing the child's behavior with a specific directive Placing the child in a time-out
The health care provider prescribes donepezil (Aricept) 5 mg by mouth once a day for a client exhibiting initial signs of dementia of the Alzheimer type. The client is already taking digoxin (Lanoxin) 0.125 mg in the morning and alprazolam (Xanax) 0.5 mg twice a day. What should the nurse teach the client's spouse to do?
Prefill a weekly drug box with the medications for the spouse to self-administer
What should the nurse do when a client with the diagnosis of schizophrenia talks about being controlled by others?
React to the feeling tone of the client's delusion
A housekeeping staff member in a mental health unit reports to the nurse that food was found hidden in a client's room. Knowing that the client was admitted with a fluid and electrolyte imbalance because of anorexia nervosa, the nurse should ask housekeeping personnel to:
Report it to the nursing staff if this happens again
A nurse is caring for an older adult with the diagnosis of dementia. Which manifestations are expected in this client? (Select all that apply.)
Resistance to change Inability to recognize familiar objects Inability to concentrate on new activities or interests Tendency to dwell on the past and ignore the present
A nurse begins a therapeutic relationship with a client with the diagnosis of schizotypal personality disorder. What is the best initial nursing action?
Respecting the client's need for social isolation
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?
Restricting the client's access to the bedroom
A constructive but lengthy method of confronting the stress of adolescence and preventing a negative and unhealthy developmental outcome is:
Role experimentation
During the first month in a nursing home, an older client with dementia demonstrates numerous disruptive behaviors related to disorientation and cognitive impairment. What should the nurse take into consideration when planning care?
Stressors that appear to precipitate the client's disruptive behavior
A young adult client with schizophrenia is prescribed haloperidol (Haldol). When the nurse administers the medication, the client asks, "What's this for?" The nurse responds that the medication:
Will help him relax and think more clearly
What clinical findings may be expected when a nurse cares for an individual with an anxiety disorder? (Select all that apply.)
Worrying about a variety of issues Converting the anxiety into a physical symptom Displacing the anxiety onto a less threatening object Demonstrating behavior common to an earlier stage of development
A depressed client is concerned about many fears that are upsetting and frightening and expresses a feeling of having committed the "unpardonable sin." What is the most therapeutic response by the nurse?
Your thoughts are just a part of your illness, and they'll change as you get better."
A hospitalized client with a mood disorder begins to be less hyperactive. One day the client says to the nurse, "My husband and I have problems getting along sometimes. We see things differently." Which response is nontherapeutic?
"You seem calmer today than you have been the last several days."
Electroconvulsive therapy (ECT) is a mode of treatment that is used primarily to treat:
Clinical depression
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?
Gestures
The nurse is caring for a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis? (Select all that apply.)
Grandiosity Talkativeness Distractibility
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 implanted when the client arrives on the unit? (Select all that apply.)
Obtaining vital signs Assessing for suicidal thoughts Instituting continuous monitoring Initiating a therapeutic relationship Inspecting the bandages for bleeding
