Psychosocial Integrity

The emergency department charge nurse should obtain a social service consult for which client? 1. A 6 year old ingested diluted bleach. 2. A 10 year old that suffered burns in a house fire. 3. A 12 year old that fractured his arm in a fight at school. 4. A 16 month old without any oral intake for the last 12 hours.

1. Correct: In most areas, laws mandate certain situations/circumstances involving children be reported to social services/child protection. Among these things are: ingestion of toxic substances, fractures, suspected neglect or abuse, burns. For older children and adults, the healthcare provider uses their judgment as to whether the situation indicated neglect or abuse by the parents or caregivers.

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

1. Correct: Decreased levels of norepinephrine, dopamine, and serotonin are neurotransmitter implications for depression.

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

2. Correct: Most clients require an average of 6 to 12 treatments, but some may require up to 20 treatments.

A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops slurred speech, shuffling gait and drooling. Which prescribed PRN medication would the nurse administer? 1. Lorazepam 2. Atropine 3. Benztropine 4. Chlorpromazine

3. Correct: These signs and symptoms are reflective of pseudoparkinsonism, a form of extrapyramidal side effects which are side effects of the haloperidol. An anticholinergic agent maybe used for treatment. This is an anticholinergic agent that may be used for extrapyramidal side effects.

A frightened client comes to the nurses' station during the night and reports hearing the voice of the devil speaking to them. Which response by the nurse is priority? 1. Could you have overheard the staff talking at the desk? 2. I will get you some medication for anxiety. 3. What did the voice tell you? 4. You do not have to worry about this. You are safe.

3. Correct: The most important thing the nurse needs to find out is what the voice was telling the client. This is a safety issue.

What kind of comments should the nurse expect from a client exhibiting clang associations? 1. Concrete explanations for abstract ideas 2. Reporting very small details when explaining something 3. Comments that are illogically associated 4. Use of rhyming words when talking

4. Correct: The client may use rhyming words, such as dog, bog, cog, jog.

A staff nurse decides to go to lunch with a friend instead of meeting with a study group for a certification exam. The staff nurse informs the clinical specialist, "Studying more will not do any good anyway." What defense mechanism does the clinical specialist understand that the staff nurse is exhibiting? 1. Rationalization 2. Denial 3. Regression 4. Reaction formation

1. Correct: Rationalization is the mind's way of justifying behavior by offering an explanation other than a truthful response. This is often used to avoid embarrassment.

A nurse is caring for a client that is undergoing outpatient psychiatric treatment for somatization disorder. Which statement by the client indicates that teaching has been successful? 1. "I will keep a diary of times of stress and the appearance of physical symptoms." 2. "I will simply ignore any physical complaints I get from now on." 3. "The best way for me to stop having physical symptoms is to avoid any stress in my life." 4. "I will take a sedative when I start having physical complaints."

1. Correct: This will help the client see the relationship between stress and physical symptoms, which is the first step in recognizing that the symptoms are related to stress.

A client being treated in the intensive care unit following methamphetamine intoxication states, "Snakes are crawling all over the room, get me out of here!" How does the nurse document this assessment finding? 1. Delusions 2. Hallucinations 3. Flashbacks 4. Depersonalization

2. Correct: Hallucinations are false sensory perceptions not associated with real external stimuli.

A client is admitted to a chemical dependency unit for addiction treatment. Which of the client's belongings should the nurse remove from the client's room? 1. Shampoo and conditioner 2. Mouthwash and hand sanitizer 3. Toothpaste and dental floss 4. Lotion and foot powder

2. Correct: Mouthwash and hand sanitizers have alcohol in them, which the client may drink.

The nurse is talking with the spouse of an alcoholic client. Which statement by the client's spouse is evidence of co-dependent behavior? . "I am frequently telling my husband that his drinking is ruining our relationship." 2. "I go and pick my husband up from the bar when he does not get home by midnight." 3. "I do not go out drinking with my husband." 4. "I have told my husband that I am willing to go with him when he wants to get help to stop drinking."

2. Correct: She is attempting to please her husband. Codependent people are people pleasers, and attempt to make excuses for others.

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

2. Correct: Violence is likely to escalate and may become lethal when the spouse leaves the abusive partner.

The parents of a 2 year old child diagnosed with autism spectrum disorder (ASD) ask the nurse what led the primary healthcare provider to diagnose this disorder for their child. What behaviors will the nurse indicate as signs of autism spectrum disorder? Select all that apply: 1. Delusions 2. Twisting 3. Preoccupation with objects 4. A personal language 5. Changes are easily tolerated.

2., 3. & 4. Correct: All are behaviors seen in children with ASD. Additionally, they often do not form interpersonal relationships with others, or play well with others.

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

3. Correct: Clients who have attempted suicide may come up with another plan. Once they do, they are generally happy, satisfied, and begin giving away personal belongings. Clients usually exhibit some trepidation about leaving the hospital.

A client is transported to the emergency department by the police following a sexual assault. What is the nurse's priority intervention? 1. Instruct the client to remove all of her clothes so they can be bagged as evidence. 2. Ask the client to describe what happened 3. Tell the client she is safe here. 4. Perform a rape kit in order to preserve the evidence

3. Correct: The client who has been sexually assaulted often experiences great fears and must be reassured of her safety. She may also be overwhelmed with self-doubt and self blame. This statement will instill trust.

A client who has a history of major depression is in the emergency department. Which statement would demonstrate a risk for suicide or self-directed injury? 1. "I can't do anything right anymore." 2. "I am not sure what to do anymore." 3. "I just cannot take this loneliness anymore." 4. "No one cares about me."

3. Correct: This statement indicates that the person cannot tolerate the current situation, so this should alert the nurse to watch this client carefully.

A client is seen in the clinic for recurrent, unexplained, vague stomach pain over the past 5 years. EGD, colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the pain. The client tells the nurse, "the pain is so bad sometimes that I can't function!" What disorder is this client likely experiencing? 1. Conversion disorder 2. Pseudocyesis 3. Somatization disorder 4. Dysmorphic disorder

3. Correct: Somatization disorder is a syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychosocial distress and long-term seeking of assistance from healthcare professionals. Symptoms are vague, dramatized, or exaggerated in presentation.

An adult client experiencing a manic episode tells the night nurse, "If you do not go to bed with me, I am going to have you fired." What is the nurse's best response? 1. That is inappropriate behavior. I will have to send you to your room if you say that again. 2. You've got to be kidding! You can't get me fired. 3. I don't want to hear that again; don't ever say that again. 4. I can see that you need attention, but this is not the way to get it.

1. Correct: Set limits on manipulative behaviors. Explain what is expected and what the consequences are if limits are violated.

A client has been admitted voluntarily to the psychiatric unit. During the admitting interview, the client confides to the nurse that he has a lethal plan for committing suicide. At the end of the interview the client asks the nurse, "How long will I have to stay here?" What should the nurse say to this client? 1. "Let's discuss this after the health team has assessed you." 2. "Since you signed papers to be admitted, you cannot leave until the primary healthcare provider discharges you." 3. "A lawyer will have to make that decision." 4. "You can leave when you are no longer suicidal."

1. Correct: A client may sign out of the hospital at any time, unless following a mental status examination the healthcare professional determines that the client may be harmful to self or others and recommends that the admission status be changed from voluntary to involuntary.

A five year old is in kindergarten and goes to the nurse's office where she reports a "stomachache". While there, the nurse observes that the child has a large bruise on her upper arm and bruises on both ears. What should the nurse do first? 1. Ask the student about the bruises on her arms and ears. 2. Do nothing as bruises are common in 5 year old children. 3. Report the injuries immediately to the parents. 4. Discuss the findings with the child's teacher.

1. Correct: Assessment and gathering information should be the first response. The child may have experienced a severe accident that does not indicate abuse. The nurse needs further information before assuming abuse in the family.

A nursing student observes a psychiatric client sitting alone. The client is talking, but occasionally stops and leans to the side as if listening to someone. The client then laughs. What is this client most likely experiencing? 1. Auditory hallucinations 2. Delusions 3. Catatonic excitement 4. Anergia

1. Correct: Auditory hallucinations are false sensory perceptions of sound not associated with real external stimuli.

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

1. Correct: Be accepting of client and spend time with him or her, even though pessimism and negativism may seem objectionable. Focus on strengths and accomplishments, and minimize failures.

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

1. Correct: Pain is real even if it is psychological pain. The client is experiencing the pain through stomach pain.

The nurse is caring for a client who is preparing to undergo a total hysterectomy for advanced cervical cancer. The client is crying and states, "I want to have more children, and I am unsure if I should have the procedure." What should the nurse do? 1. Allow the client to discuss her fears, and encourage her to talk more with her primary healthcare provider. 2. Discuss the good things that she will be able to do without more children, and encourage her to make a list of positive things. 3. Explain to the client that her ovaries can be frozen for egg harvesting at a later time, and she can find a surrogate. 4. Advise the client to put off having the surgery until she is certain, and notify the surgeon of the decision.

1. Correct: This is likely anticipatory grieving and fear. Let the client talk and encourage her to talk again to the primary healthcare provider. The client needs reassurance that she is making the right decision.

The nurse routinely screens injury victims for the possibility of intimate partner violence (IPV). Which statement correctly supports the nurse's action? 1. Victims of abuse are likely to report injuries and causes that do not fit the normal profile. 2. IPV is not routinely seen in the upper socioeconomic level. 3. All women should be screened, but men are not routinely screened. 4. Only victims who enter the emergency department alone should be screened for IPV.

1. Correct: Victims of abuse most often report causes of injuries that don't fit with the type of injury observed. For example, a victim may report that a bruised eye came from "running into" a door.

The home care nurse is caring for a group of clients. Which client is at highest risk for suicide? 1. 76 year old widower with chronic renal failure 2. 19 year old with new SSRI therapy 3. 28 year old post-partum crying weekly 4. 50 year old client with obsessive-compulsive disorder (OCD) and depression

1. Correct: Yes, elderly with chronic disease, especially men are very high risk.

The nurse manager is planning a leadership development workshop for new charge nurses. Which components of the communication cycle should the manager include as necessary for effective verbal communication? Select all that apply: 1. There is a sender for every message. 2. A clear message is formulated. 3. There is a receiver for every message. 4. The sender and receiver share the same life experiences. 5. There can be incongruence between the verbal and nonverbal message.

1., 2. & 3. Correct: The communication cycle includes the sender, a clear and concise message, the receiver, plus verbal or nonverbal feedback to acknowledge understanding of the message.

A nurse is developing a proposal to implement a pet therapy program at a nursing home. What information should the nurse include in the proposal to support this program? Select all that apply: 1. Evidence has shown that animals can directly influence a persons mental and physical well-being. 2. Bringing a pet into a nursing home for the elderly has been shown to enhance social interaction. 3. Although petting a cat does not lower blood pressure, it can decrease the effects of loneliness. 4. Some researchers believe that animals actually may retard the aging process among those who live alone. 5. There is a slight possibility that pet therapy may help some nursing home clients.

1., 2. & 4. Correct: All of these statements are correct in reference to pet therapy programs.

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

1., 2. & 5. Correct: Initially meet the client's dependency needs as required to keep anxiety from escalating. Rituals may interfere with client elimination needs. Establishing a regular schedule may prevent constipation.

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

1., 2., 3., & 5. Correct: The client with severe depression has extremely low self-esteem and low energy levels, and may just sit for hours. The room environment mimics the mood of the client. The client may not have the energy to bathe, change clothes, or even comb hair. The severely depressed person may have severe insomnia. Sleeping too much is also a symptom of mild depression.

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

1., 2., 4. & 5. Correct: It is important to be direct and non-secretive with suicidal clients. It is appropriate to express concern for their thoughts. Resources for assistance are important to include in all health teaching programs. The client contemplating suicide should not be left alone.

The crisis line nurse answers a call from a client who is voicing intent to commit suicide. The client tells the nurse, "I am sitting here with a bottle of pain killers in my hand." What is the nurse's most appropriate response? Select all that apply: 1. "I want to help you to resolve the problem." 2. "You should drive yourself to the emergency room." 3. "You did the right thing by calling." 4. "I want you to stay on the phone with me." 5. "Have another person call 911 for an ambulance."

1., 3., 4. & 5. Correct: The nurse wants to establish a positive relationship with the client as quickly as possible. The nurse wants to recognize positive qualities. Keeping the client on the phone may prevent the client from taking the pain killers. Losing contact is a threat to the client's safety. This client is planning action, with access to the plan. Emergency personnel should be called.

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

1., 3.,4. & 5. Correct: Trust is demonstrated through nursing interventions that convey a sense of warmth and care to the client. These interventions are initiated simply, concretely, and directed toward activities that address the client's basic needs for physiological and psychological safety and security. Concrete thinking focuses thought processes on specifics, rather than generalities, and immediate issues, rather than eventual outcomes. Examples of nursing interventions that would promote trust in an individual who is thinking concretely include such things as: providing a blanket when the client is cold, providing food when the client is hungry, keeping promises, being honest, providing a written, structured schedule of activities, attending activities with the client if he is reluctant to go alone, being consistent in adhering to unit guidelines, and taking the client's preferences, requests, and opinions into consideration when possible in decisions concerning care.

Which interventions are appropriate for the nurse to identify for a client admitted to the psychiatric unit for management of anorexia nervosa? Select all that apply: 1. Weigh daily 2. Allow only 20 minutes of exercise daily 3. Allow the client to bargain for privileges as long as the client eats. 4. Stay with the client during the established time for meals. 5. Maintain visual observation for 1 hour following meals.

1.,4. & 5. Correct: Weigh daily, immediately upon rising and following morning void, using same scale if possible. The established time for meals is usually 30 minutes. This takes the focus off of food and eating and provides the client with attention and reinforcement. The hour following meals may be used to discard food stashed from tray or to engage in self-induced vomiting.

How might a personal tendency toward stereotyping and countertransference affect the nurse's ability to complete a client's cultural assessment? 1. Facilitate the treatment process 2. Fail to recognize unmet needs of the individual client 3. Be open and honest while responding to the client's concerns 4. Anticipate the unmet needs of the individual client.

2. Correct: Both stereotyping and countertransference will decrease the nurse's sensitivity to the client's needs and the culture they represent.

The nurse on an inpatient psychiatric unit has been assigned to care for a group of clients. Which client should receive priority in morning round assessment? 1. 40 year old woman who is being discharged today. 2. 80 year old man with a history of suicidal thinking. 3. 45 year old man who has a history of suicidal thinking. 4. 50 year old woman with history of acute panic attacks.

2. Correct: Elderly males have the highest risk of suicide in the US.

A client admitted to the psychiatric unit is diagnosed with depression. During the admitting interview ,the client begins to cry and tells the nurse, "My life is useless now that my boyfriend has left me." What is the nurse's best response? 1. I understand what you are feeling. I have been left by a man I loved before. I get very angry when people say I need to just get over him. 2. You feel upset and unhappy by the loss of your boyfriend? It is ok to cry. 3. Don't worry. You will feel better once we start giving you medication for depression. 4. Crying isn't going to help anything. Let's talk about your past medical history now.

2. Correct: Empathy is the ability to see beyond outward behavior and to understand the situation from the client's point of view. Therapeutic language is necessary for this client.

The nurse is assigned to care for a client with the diagnosis of schizophrenia. The client tells the nurse, "I am having trouble tuning out the voices." What is the nurse's best response to this statement? 1. There is nothing to help with this problem. 2. You might hum when the voices are so troublesome. 3. You should ask your primary healthcare provider to increase your medication. 4. Wear earplugs

2. Correct: Humming or listening to music may help to decrease the intrusive voices.

The nurse is caring for a client in the emergency department following an argument with her husband. She describes a verbal argument that began to get physical with shoving of the client. She admits a history of domestic violence. Which phase of the cycle of violence is the client describing? 1. Honeymoon phase 2. Tension-building phase 3. Acute battering phase 4. Remorse phase

2. Correct: In the tension-building phase, minor physical violence may occur as well as verbal arguments.

A client is undergoing outpatient psychiatric treatment for somatization disorder. Prior to the beginning of group therapy, the client tells the nurse, "I keep having headaches that are killing me! This has never happened to me before." What is the nurse's best response to this client? 1. We need to start the group session now. 2. I will tell the primary healthcare provider about your headaches. For now, let's start our group session. 3. I guess we can discuss your pain now. Group therapy will have to start later. 4. Your headaches are not real, so ignore them. Go on into therapy so we can start.

2. Correct: Initially, the nurse would fulfill the client's urgent dependency needs, but gradually withdraw attention to physical symptoms. Minimize time given to response to physical complaints. Gradual withdrawal of positive reinforcement will discourage repetition of maladaptive behavior. However, all new symptoms should be reported to ensure physician assessment of the complaint.

The nursing staff have not been able to control the outbursts of a violent adult client. The primary healthcare provider prescribes physical restraints to be applied for the next 8 hours. What is the nurse's best action? 1. Apply the restraints for the 8 hours, with a trial release every 2 hours. 2. Explain to the primary healthcare provider that the order for restraints will have to be reissued in 4 hours. 3. Refuse to place the client in restraints unless the primary healthcare provider gets a permit signed from the family. 4. Apply the restraints, and observe the client hourly.

2. Correct: Orders for restrains or seclusion must be reissued by a primary healthcare provider every 4 hours for adults age 18 and older, every 2 hours for children and adolescents ages 9-17, and every hour for children less than 9 years.

A schizophrenic client tells the nurse, "The President of the United States just told me to leave the hospital immediately because a spy is on the way to tap into the secret information in my brain." What is the nurse's best response? 1. The voice you heard is because of your illness and will go away in time. 2. I know you think the President of the United States is talking to you, but I do not see the President. We are the only ones here. 3. I find it hard to believe that you have talked to the President of the United States. This is not the White House! 4. I think the primary healthcare provider needs to increase your medication dose, since you are still hearing voices.

2. Correct: The correct answer is to present reality. When a client has a misperception of the environment, the nurse defines reality or indicates his or her perception of the situation to the client.

A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What is the client most likely experiencing? 1. Hyperventilation 2. Panic disorder 3. Somatization 4. Conversion disorder

2. Correct: These are all signs of panic disorder. Additional s/s include: sweating, feeling of choking, chest discomfort, abdominal distress, dizziness, lightheadedness, faintness, feelings of unreality or being detached from self, fear of losing control, fear of dying, Paresthesias, chills or hot flashes.

A client at the outpatient clinic has difficulty with assertive communication. The nurse overhears this client responding on the phone when his boss asks him to work an extra night shift. Which statement by the client demonstrates assertive communication? 1. "I know you are joking. I have already worked an extra night shift." 2. "I do not want to work an extra night shift. I have already worked an extra shift this week." 3. "Umm, well, okay. I guess I will work an extra night shift." 4. "Okay, I'll work an extra night shift." Then he says to another client."The nerve of my boss to ask me to work another extra shift."

2. Correct: This is an example of assertive communication, the best response.

The nurse has been educating a client diagnosed with general anxiety disorder (GAD). Which statement by the client indicates the need for further education? 1. "I will avoid caffeine from now on." 2. "When I feel anxious I will increase my breathing to get more oxygen to my brain." 3. "I will go for a brisk walk when I begin to feel anxious." 4. "I will keep a diary of anxiety attacks to determine what triggers them."

2. Correct: This is an incorrect statement. The client needs to slow breathing down with deep-breathing exercises.

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

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

A client has been admitted to the psychiatric unit with a diagnosis of schizophrenia. Which client behaviors does the nurse anticipate? Select all that apply: 1. Slumped posture 2. Waxy flexibility 3. Grandiosity 4. Anxiety 5. Agitated behavior

2., 3. & 5. Correct: Waxy flexibility describes a condition in which the client allows body parts to be placed in bizarre or uncomfortable positions for long periods of time. Grandiosity and agitated behavior are signs and symptoms of schizophrenia.

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

2., 3., 4. & 5. Correct: A common myth is that the person who doesn't talk about suicide will not attempt it, but this may be a warning sign that the person has a well thought out plan. Warning signs generally exist but may not be recognized by others until after the suicide or attempted suicide. Once a person has made a suicidal attempt, the chances increase that they will attempt it again at a later time. Sudden behavioral changes can signal suicidal intentions

A young adult client frequently engages in high risk behaviors, including driving at high speeds, using alcohol in excess, and engaging in high risk sexual behaviors. Which problem is priority for the nurse to assess? 1. Antisocial personality traits causing the disregard for life. 2. Impaired judgement caused by arrested maturation. 3. Unconscious suicidal thoughts being present. 4. Unhealthy grieving occurring.

3. Correct: Since all the behaviors could lead to death, these are considered indicators of self-destructive behaviors.

The nurse is planning a teaching session with the family members of a client diagnosed with advanced Alzheimer's disease. Which topic is most important for the nurse to discuss? 1. Encouraging dependence on family members 2. Performing passive range of motion 3. Providing a safe environment 4. Monitoring vital signs every 8 hours

3. Correct: A safe home environment is priority to prevent falls and injuries.

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

3. Correct: A stimulating environment may increase the level of anxiety.

The nurse is caring for a 5-year old child brought to the Emergency Department by the parents for pain and swelling in the left arm. An x-ray of the arm confirmed a fracture. The parents give conflicting stories about the accident. What action by the nurse is most appropriate? 1. Prepare the child for casting of the arm. 2. Ask the primary healthcare provider to order bone series film. 3. Consult social services. 4. Obtain a history as to how the accident happened.

3. Correct: All states have laws that mandate reporting of child maltreatment. Usually the social service department handles these types of referrals.

The school nurse has been observing a 13 year-old student during the past few months as the student has steadily lost weight. Which assessment finding would indicate the beginning of an eating disorder? 1. Clothing size has decreased by 2 sizes. 2. Student eats most meals with peers. 3. Client reports a fear of gaining weight. 4. Diet consists mostly of fruit or raw vegetables.

3. Correct: An adolescent reporting a fear of gaining weight may indicate the beginning of an eating disorder.

The nurse is caring for a depressed client. The client has a flat affect, apathy, and slowed physical movement. The client has not bathed in several days and there is a malodorous odor noted. Which intervention would be most appropriate at this time? 1. Explain the rules about daily showers. 2. Leave the client alone since there is slowed movement. 3. Tell the client it is time to take a shower. 4. Ask when he or she would like to take a shower.

3. Correct: Depressed clients often have little energy to do or think. Give short, simple commands during this time

The clinical specialist is teaching a group of new staff nurses about therapeutic communication. Which statement by one of the staff nurses indicates to the clinical specialist that further teaching is needed? 1. Effective communication involves feedback to let the sender know that the message was understood by the receiver. 2. An effective message should be clear and complete. 3. Therapeutic communication does not include the use of gestures. 4. I must listen with a "third ear" to be aware of what the client is not saying.

3. Correct: Gestures are a type of nonverbal communication which can provide assistance in communicating therapeutically with a client. Other forms of nonverbal communication include facial expression, touch, mannerisms, posture, position, and personal space.

A float nurse arrives on the unit to assist in the care of clients for a shift. During report, the charge nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. Based on this information,what should the unit nurse do? 1. Ask the float nurse, "Have you been drinking?" 2. Assign the float nurse to the least acute clients. 3. Notify the nursing supervisor to report the observations. 4. Notify the state board of nursing that the float nurse is an alcoholic.

3. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. Confrontation should occur in the presence of a supervisor or other nurse and should include the offer of assistance in seeking treatment.

After the unexpected death of a Jewish teenager, the coroner tells the family that an autopsy has been requested. The teen's mother starts crying hysterically and refuses to allow the autopsy. After calming the mother, what should the nurse do? 1. Explain that the coroner does not need the family's permission to perform the autopsy. 2. Ask the primary healthcare provider for a sedative for the mother. Notify the coroner. 3. Notify the coroner that the family is Jewish. Judaism does not allow mutilation of the body. 4. Call the Rabbi of the family's synagogue to discuss the nature of the autopsy.

3. Correct: Mutilation of the body is forbidden. Autopsy is allowed only when mandated by civil authorities, such as when murder is suspected.

A psychotic client tells another client, "You are so adorabogalishus." Which form of thought process should the nurse document this client as having? 1. Magical thinking 2. Tangentiality 3. Neologism 4. Perseveration

3. Correct: The psychotic person invents new words, or neologisms, that are meaningless to others but have symbolic meaning to the psychotic person.

The nurse is caring for a client in an outpatient clinic. The client's spouse died 8 months ago. Which statement by the client suggests that the client is achieving resolution of grief? 1. "I am starting a new life, so I have removed all of the pictures from the wall that remind me of my spouse." 2. "I have started having tremors during the day. Perhaps something is wrong with me." 3. "Although it hasn't been easy, I accept the loss of my soul mate." 4. "If only we had spent more time together before the illness got so severe."

3. Correct: This client has begun to achieve resolution of grief by walking through the tasks of mourning: to accept the reality of the loss, to experience the pain of grief, to adjust to an environment in which the deceased is missing, and to withdraw emotional energy and perhaps invest in another relationship.

A client is hospitalized because of severe malnutrition related to anorexia nervosa. What is the most important goal for this client? 1. Verbalize understanding that eating behaviors are maladaptive. 2. Verbalize the importance of adequate nutrition. 3. Achieve at least 80% of expected body weight. 4. Acknowledge misperception of body image as fat.

3. Correct: Until appropriate weight is gained, the client continues to be at risk for major health complications including hypotension, cardiac arrhythmias, poor muscle tone, increased risk for infection, abnormal liver function, and damaged kidneys.

The nurse makes selections from the hospital menu for a client who is confused and suspicious of others. Which menu choice is best? 1. Ham and vegetable casserole 2. Cheese and crackers 3. Caffeine free tea 4. Packaged sugar free jello

4. Correct: A client who is suspicious of others needs foods that are packaged and can see them opened.

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

4. Correct: A client with Alzheimer's is likely to recognize a familiar object.

Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is in the acute phase of mania? 1. Sit with the client during meals to encourage the client to eat all foods on the tray. 2. Assess the clients food preferences and provide only those foods for the client at meal time. 3. Allow the client to eat in the dining room with other clients. 4. Provide high-protein, high calorie snacks on the nursing unit between meals.

4. Correct: Having nutritious foods available between meals may help to increase the client's food intake. Nutritious intake is required on a regular basis to compensate for increased caloric requirements due to the hyperactivity.

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

4. Correct: Here the nurse is speaking only for the nurse. The nurse cannot legitimately speak for anyone else. The nurse must model the process of not speaking for anyone else.

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

4. Correct: Multimodal treatment of ADHD is the standard of care for children. There is a lot to be gained by supporting medication treatment with appropriate educational, psychosocial, and family interventions.

An elderly client comes to the clinic for a check-up. The client's daughter tells the nurse that her father's dementia symptoms become increasingly more difficult to handle in the evening. How would the nurse document this symptom? 1. Confabulation 2. Apraxia 3. Pseudodementia 4. Sundowning

4. Correct: Sundowning is a phenomenon where symptoms seem to worsen in the late afternoon and evening. Communication becomes more difficult, with increasing loss of language skills. Institutional care is usually required at this stage.

The nurse has been working with a client who has a diagnosis of schizophrenia. The client has had three inpatient admissions in the past, but none for the most recent 6 months. Which statement by the client indicates adequate understanding of the medication treatment regimen? 1. I am feeling better so I hope that I don't have to take the medication for long. 2. I can stop the medication after I have been out of the hospital for a year. 3. The medicine is good for me now; however, I don't want to take it forever. 4. The medication keeps me out of the hospital, and I don't want to hear voices again.

4. Correct: The client must take the medicine long-term. If the client makes the connection between the medicine and feeling better, adherence is more likely.

The nurse has been talking with a depressed client at an outpatient clinic. When asked how the client feels to live alone, the client simply stares straight ahead. How should the nurse respond? 1. Ask, "Why won't you answer me?" 2. Leave the client alone for awhile. 3. Tell a joke to lighten the mood. 4. Use therapeutic silence.

4. Correct: Use of silence allows the client time to think over what he or she wants to say and gives the client a chance to collect thoughts.

The client with obsessive-compulsive disorder (OCD) asks the nurse for help with a repetitive behavior. What is most likely the origin of this behavior? 1. Fear 2. Depression 3. Delusions 4. Anxiety

4. Correct: Yes, this is how they deal with anxiety.

What is the priority nursing intervention when caring for a client with an eating disorder? 1. Encourage client to cook for others 2. Weigh the client daily and keep a journal 3. Restrict access to mirrors 4. Monitor food intake and behavior for one hour after meals

4. Correct: Yes, this is the primary problem and the most life-threatening.