Review question for chapter 54,55,56 Psyc

Disulfiram (Antabuse) is prescribed for a client who is seen in the psychiatric health care clinic. The nurse is collecting data on the client and is providing instructions regarding the use of this medication. Which is most important for the nurse to determine before administration of this medication? a. A history of hyperthyroidism b. A history of diabetes insipidus c. When the last full meal was consumed d. When the last alcoholic drink was consumed

d. When the last alcoholic drink was consumed

A nurse is collecting data from a client and the client's spouse reports that the client is taking donepezil hydrochloride (Aricept). Which disorder would the nurse suspect that this client may have based on the use of this medication? a. Dementia b. Schizophrenia c. Seizure disorder d. Obsessive-compulsive disorder.

a. Dementia

A client is admitted to a psychiatric unit for treatment of psychotic behavior. The client is at the locked exit door and is shouting, "Let me out! There is nothing wrong with me! I don't belong here!" The nurse identifies this behavior as: a. Denial b. Projection c. Regression d. Rationalization

a. Denial

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member would indicate the client has learned positive coping skills? a. "I will be more careful to make sure that my father's needs are met." b. "Now that my father is moving into my home, I will need to change my ways." c. "I feel better able to care for my father now that I know where to obtain assistance." d. "I am so sorry and embarrassed that the abusive event occurred. It won't happen again."

c. "I feel better able to care for my father now that I know where to obtain assistance."

A nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time? a. "I know you feel 'they are out to get you,' but it's not true." b. "I can hear the voice and she wants you to come to dinner." c. "Sometimes people hear things or voices others can't hear." d. "I talked to the voices you're hearing and they won't hurt you now."

c. "Sometimes people hear things or voices others can't hear." Why? a, b & d do not reinforce reality

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse would be: a. "Why don't you tell your husband about this?" b. "This is not the best time to make that decision" c. "What do you find difficult about this situation?" d. "I agree with you. You should get out of this situation."

c. "What do you find difficult about this situation?" Why? encourages client to problem solve. Giving advice implies that nurse knows best. a-would never use 'why' b-not this one it puts clients feelings on hold d. just agrees with client

A clients says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all I'm the one who's dying." The therapeutic response by the nurse is: a. "Have you shared your feelings with your family?" b. "I think we should talk more about your anger with your family." c. "you're feeling angry that your family continues to hope for you to be 'cured'/" d. "Well, it sounds like you're being pretty pessimistic. After all, years ago people died of pneumonia."

c. "you're feeling angry that your family continues to hope for you to be cured'!" Why? Therapeutic communication technique that redirects the client's feelings back to validate what the client is saying.

An intoxicated client is brought to the emergency department by local police. The client is told that the health care provider(HCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the HCP immediately. The nurse assisting to care for the client would plan for which of the appropriate nursing intervention? a. Watch the behavior escalate before intervening b. Attempt to talk with the client to de-escalate the behavior c. Offer to take the client to an examination room until he or she can be treated. d. Inform the client that he or she will be asked to leave if the behavior continues

c. Offer to take the client to an examination room until he or she can be treated. Why? An effect of isolation that allows for separation from others (for others safety) and provides a less stimulating environment

A nurse is caring for a hospitalized client who has been taking clozapine (Clozaril) for the treatment of a schizophrenic disorder. Which laboratory study prescribed for the client will the nurse specifically review to monitor for an adverse effect associated with the use of this mediation? a. Platelet count b. Cholesterol level c. WBC count d. Blood urea nitrogen level

c. WBC count

A psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." The appropriate nursing response is which of the following? a. "I cannot discuss any client situation with you>" b. "I'm not supposed to discuss this, but since you are my neighbor, I can tell you that she is doing great!" c. "You may want to know about Carol, so you need to ask her yourself so you can get the story firsthand." d. "I'm not supposed to discuss this, but since you are my neighbor, I can tell you that she really has some problems!"

a. "I cannot discuss any client situation with you." Why? HIPPA

A nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Alon group when the nurse hears the wife say: a. "I no longer feel that I deserve the beatings my husband inflicts on me." b. "My attendance at the meetings has helped me to see that I provoke my husband's violence." c. "I enjoy attending the meetings because they get me out of the house and away from my husband." d. "I can tolerate my husband's destructive behaviors now that I know they are common in alcoholics."

a. "I no longer feel that I deserve the beatings my husband inflicts on me. notice 'benefiting from attending'

A nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse avoids which intervention in the plan of care? a. "Right! Why not just 'pack it in'?" b. "That seems rather unlikely to me." c. " I don't believe that, and neither do you." d. "You must be feeling all alone at this point."

a. "Right! Why not just 'pack it in'?"

A client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has: a. Agoraphobia b. Hematophobia c. Claustrophobia d. Hypochondriasis

a. Agoraphobia Why? Agoraphobia 'fear of being alone in open places where escape might be difficult. b-Hematophobia is a 'fear of blood' c. Claustrophobia is a 'fear of closed in places' d. Hypochondriasis, their symptoms would focus on anxiety and physical complaints and they are preoccupied with their health.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. The appropriate nursing action is to: a. Call the nursing supervisor b. Call security to block all exit areas c. Restrain the client until the health care provider (HCP) can be reached. d. Tell the client that she cannot return to this hospital again if she leaves now.

a. Call the nursing supervisor Why? A nurse can be charged with false imprisonment if a client is made to wrongfully believe that they cannot leave the hospital. They need to sign an AMA, leaving against medical advice. d- any pt has right to medical health care and cannot be told otherwise also eliminate b & c because they are alike and include false imprisonment

A licensed practical nurse (LPN) enters a client's room, and the client is demanding release from the hospital. The LPN reviews the client's record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder, and that the admission was a voluntary admission. The LPN reports the findings to the registered nurse (RN) and expects that the RN will take which of the following actions? a. Contact the health care provider (HCP) b. Call the client's family c. Persuade the client to stay a few more days. d. Tell the client that discharge is not possible at this time.

a. Contact the health care provider (HCP) Why? 'voluntary' admission

A nursing student is asked to identify the characteristics of bulimia nervosa. Which response by the student indicates a need to further research the disorder? a. Dental erosion b. Electrolyte imbalances c. Enlarged parotid glands d. Body weight well below ideal range

a. Dental erosion

A manic client announces to everyone in the day-room that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action would be to: a. Escort the manic client to his or her room b. Orient the client to time, person, and place. c. Tell the client that the behavior is not appropriate d. Tell the client that smoking privileges are revoked for 24 hours.

a. Escort the manic client to his or her room Why? The client is at risk for injury as well as others. b-Orientation will not halt behavior only orient him to time & place c-Telling client it is inappropriate has already been done by aide. d-Will only make it worse

A client experiencing a severe major depressive episode is unable to address activities of daily living. The appropriate nursing intervention is to a. Feed, bathe, and dress the client as needed until the client can perform these activities independently b. Offer the client choices and consequences to the failure to comply with the expectation of maintaining activities of daily living c. Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for the activities of daily living. d. Have the client's peers confront the client about how the noncompliance in addressing activities of daily living affects the milieu.

a. Feed, bathe, and dress the client as needed until the client can perform these activities independently

A hospitalized client is started on phenelzine sulfate (Nardil) for the treatment of depression. The nurse instructs the client to avoid consuming which foods while taking this medication? (Select all that apply) a. Figs b. Yogurt c. Crackers d. Aged cheese e. Tossed salad f. Oatmeal cookies

a. Figs b. Yogurt d. Aged cheese

Which of the following are appropriate interventions for caring for the client in alcohol withdrawal? (Select all that apply) a. Monitor vital signs b. Maintain an NPO status. c. Provide a safe environment d. Address hallucinations therapeutically e. Provide stimulation in the environment f. Provide reality orientation as appropriate

a. Monitor vital signs c. Provide a safe environment d. Address hallucinations therapeutically f. Provide reality orientation as appropriate

A client taking buspirone (BuSpar) for 1 month returns to the clinic for a follow-up visit. Which of the following would indicate medication effectiveness? a. No rapid heartbeats or anxiety b. No paranoid thought processes c. No thought broadcasting or delusions d. no reports of alcohol withdrawal symptoms

a. No rapid heartbeats or anxiety.

A nurse is assisting in planning care for a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention will the nurse include in the plan of care? a. One to one suicide precautions b. Suicide precautions, with 30 minute checks c. Checking the whereabouts of the client every 15 minutes d. Asking that the client report suicidal thoughts immediately

a. One to one suicide precautions

A nurse is assigned to care for a client who is experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique does the nurse plan to use to encourage the client to eat? a. Open-ended questions and silence b. Focusing on self-disclosure regarding food preferences c.Stating the reason that the client may not want to eat d. offering opinions about the necessity of adequate nutrition

a. Open ended questions and silence Why? Open ended questions are used to encourage clients to discuss their problem.

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, the nurse likely expects that the client: a. Presents a harm to self b. Requested the admission c. Consented to the admission d. Provided written application to the facility for admission

a. Presents a harm to self Why? 'involuntary' note that questions b,c,d. is alike so not likely

A nurse observes that a client is psychotic, pacing and agitated and is making aggressive gestures. The client's speech pattern is rapid and the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is to: a. Provide safety for the client and other clients on the unit. b. Provide the clients on the unit with a sense of comfort and safety. c. Assist the staff in caring for the client in a controlled environment. d. Offer the client a less stimulating area to calm down and gain control.

a. Provide safety for the (client and other clients) on the unit. Why? Safety of the 'client and other clients' is the priority. b-addresses other clients' needs c-is not client centered d-addresses clients' needs

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which of the following are therapeutic communication techniques? (Select all that apply) a. Restating b. Listening c. Asking the client, "Why?" d. Maintaining neutral responses e. Giving advice or approval or disapproval. f. Providing acknowledgment and feedback.

a. Restating b. Listening d. Maintaining neutral responses f. Providing acknowledgment and feedback

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal? a. The client gives away a prized CD and cherished autographed picture of the performer. b. The client runs out of the therapy group swearing at the group leader and then runs to her room. c. The client gets angry with her roommate when the roommate borrows her clothes without asking. d. The client becomes angry while speaking on the telephone and slams the receiver down on the hook.

a. The client gives away a prized CD and cherished autographed picture of the performer.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? (Select all that apply) a. communicate expected behaviors to the client b. Ensure that the client knows that he or she is not in charge of the nursing unit. c. Assist the client in developing means of setting limits on personal behavior d. Follow through about the consequences of behavior in a nonpunitive manner. e. Enforce rules and inform the client that he or she will not be allowed to attend therapy groups. f. Be clear with the client regarding the consequences of exceeding limits set regarding behavior.

a. communicate expected behaviors to the client c. Assist the client in developing means of setting limits on personal behavior. d. Follow through about the consequesces of behavior in a nonpunitive manner. f. Be clear with the client regarding the consequences of exceeding limits set regarding behavior. Why? Set limits on personal behaviors. Enforcing rules e-its illegal to tell them they can't attend therapy power struggles need to be avoided

A client taking lithium carbonate (Lithobid) reports vomiting abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is checked as a part of the routine follow up and the level is 3.0 mEg/L. The nurse knows that this level is a. Toxic b. Normal c. Slightly above normal d. Excessively below normal

a. toxic

A client has reported that crying spells have been a major problem over the past several weeks, and that the doctor said that depression is probably the reason. The nurse observes that the client is sitting slumped in the chair and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on: a. weight loss b. sleep patterns c. medication compliance d. onset of the crying spells

a. weight loss Why? 'Priorities of care of a client with depression' All options are possible however, the weight loss is first item because ill-fitting clothes could indicate a problem with nutrition . b & c medications and sleep patterns was not mentioned in question d-client has already made you aware that crying spells is a problem

A nurse is assisting with the data collection on a client admitted to the psychiatric unit. The nurse reviews the data obtained and identifies which of the following as a priority concern? a. The client's report of suicidal thoughts b. The client's report of not eating or sleeping c. The presence of bruises on the client's body d. The family member is disapproving of the treatment.

a.The client's report of suicidal thoughts Why? Suicidal thoughts are the highest priority b,c &d will affect treatment but are not greatest importance at this time

A nurse is caring for a client who is suspected of being dependent on drugs. Which question would be appropriate for the nurse to ask when collecting data from the client regarding drug abuse? a. "Why did you get started on these drugs?" b. "How much do you use and what effect does it have on you?" c. "How long did you think you could take these drugs without someone finding out?" d. The nurse does not ask any questions because of fear that the client is in denial and will throw the nurse out of the room.

b. "How much do you use and what effect does it have on you?" Why? be nonjudgmental a-judgmental, nurse is being bias c-judgmental, insensitive and aggressive d. passive nurse that uses rationalization to avoid therapeutic nursing intervention

A nurse is providing care to a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client and the client says,"I have a secret that I want to tell you. You won't tell anyone about it, will you?" The appropriate nursing response is which of the following? a. "No, I won't tell anyone." b. "I cannot promise to keep a secret." c. "If you tell me the secret, I will tell it to your doctor." d. "If you tell me the secret, I will need to document it in your records

b. "I cannot promise to keep a secret."

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two bed hospital room. A newly admitted client will be assigned to this client's room. Which client would be an appropriate choice as this client's roommate? a. A client with pneumonia b. A client receiving diagnostic tests c. A client who thrives on managing others d. A client who could benefit from the client's assistance at mealtime.

b. A client receiving diagnostic tests Why a. no would put them at risk for pneumonia c & d would put them at further risk

A nurse is caring for a client with severe depression. Which of the following activities would be appropriate for this client? A nurse is caring for a client with severe depression. Which of the following activities would be appropriate for this client? a. A puzzle b. Drawing c. Checkers d. Paint by number

b. Drawing

The police arrive at the emergency room with a client who has seriously lacerated both wrists. The initial nursing action is to: a. Administer an antianxiety agent b. Examine and treat the wound sites c. Secure and record a detailed history d. Encourage and assist the client to vent feelings.

b. Examine and treat the wound sites

A nurse is performing a follow-up teaching session with a client discharged 1 month ago who is taking fluoxetine (Prozac). What information would be important for the nurse to gather regarding the adverse effects related to the medication? a. Cardiovascular symptoms b. Gastrointestinal dysfunctions c. Problems with mouth dryness d. Problems with excessive sweating

b. Gastrointestinal dysfunctions

A nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate? a. Interrupt the client and weigh her immediately. b. Interrupt the client and offer to take her for a walk. c. Allow the client to complete her exercise program. d. Tell the client that she is not allowed to exercise vigorously

b. Interrupt the client and offer to take her for a walk. Why? Clients with anorexia nervosa are preoccupied with vigorous exercise and push themselves beyond normal limits to work off caloric intake. a, c & d are inappropriate

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." In helping the mother prepare for her daughter's discharge, the nurse suggests that the mother: a. Restrict the daughter's socializing time with her friends. b. Restrict the amount of chocolate and caffeine products in the home. c. Keep her daughter out of school until she can adjust to the school environment d. Consider taking time from work to help her daughter readjust to the home environment.

b. Restrict the amount of chocolate and caffeine products in the home. Why? Clients with anxiety disorder should abstain from or limit their intake of caffeine, chocolate and alcohol. These products have potential of increasing anxiety. a & c are unreasonable and unhealthy d- may not be realistic ALSO a, c & d-are alike and concerned with monitoring client's physical activities where b is preparing client's environment and focuses on the concern of subject

A nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse would expect which of the following? a. The client will be angry and will refuse care. b. The client will participate in the treatment plan c. The client will be very resistant to treatment measures. d. The client's family will be very resistant to treatment measures.

b. The client will participate in the treatment plan. Why? voluntary admission so client is most likely to participate notice that a,c, & d is alike so not likely to be answer

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is to: a. Move the client next to the nurse's station b. Use a night light and turn off the television. c. Keep the television and a soft light on during the night. d. Play soft music during the night and maintain a well-lit room.

b. Use a night light and turn off the television. Why? 'initial' low stimulation environment c & d eliminate because they are similar or alike

A nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse would determine that this type of crisis could be caused by: a. Witnessing a murder b. The death of a loved one c. A fire that destroyed the client's home d. A recent rape episode experienced by the client

b. the death of a loved one

A nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which clinical manifestations are specifically associated with withdrawal from opiods? a. Dilated pupils, tachycardia, and diaphoresis b. Yawning irritability, diaphoresis, cramps, and diarrhea c. Tachycardia, hypertension, sweating, and marked tremors d. Depressed feelings, high drug craving, fatigue, and agitation

b. yawning irritability, diaphoresis, cramps and diarrhea opiods are CNS Withdrawal affects include yawning, insomnia, irritability, rhinorrhea, diaphoresis, cramps, n/v, muscle aches, chills, fever

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here?" The nurse who is present at the time should respond by stating which of the following? a. "The technician will leave and come back later for your blood." b. "What makes you think that the technician wants to hurt you?" c. "Are you fearful and think that others may want to hurt you?" d. "The technician is not going to hurt you, but is going to help you!"

c. "Are you fearful and think that others may want to hurt you?' Why? only option that recognizes client's need

Fluxetine (Prozac) is prescribed for the client. The nurse reinforces instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about administration of the medication? a. I should take the medication with my evening meal." b. "I should take the mediation at noon with an antacid" c. "I should take the medication in the morning when I first arise." d. "I should take the medication right before bedtime with a snack

c. "I should take the medication in the morning when I first arise."

A nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be appropriate to make to this client? a. "You need to stop that behavior now!" b. "You will need to be placed in seclusion!" c. "What is causing you to become agitated?" d. "You will need to be restrained if you do not change your behavior."

c. "What is causing you to become agitated?"

A nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, the most appropriate question to ask is: a. "With whom do you live?" b. "Who is available to help you? c. "What leads you to seek help now?" d. "What do you usually do to feel better?"

c. "What leads you to seek help now?"

A client who is diagnosed with pedophilia and has been recently paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters of me all over the neighborhood telling about me with my picture on it. "Which of the following is an appropriate response by the nurse? a. "When children are hurt as you hurt them, people want you isolated." b. "You're lucky it doesn't escalate into something pretty scary after your crime." c. "You understand that people fear for their children, but you're feeling unfairly treated?" d. "You seem angry, but you have committed serious crimes against several children, so your neighbors are frightened."

c. "You understand that people fear for their children, but you're feeling unfairly treated?" 'therapeutic communication' Why? Focusing the implied concern is the therapeutic response. It assists the client to clarify thinking and re-examine what the client is really saying. a-is insensitive and anxiety provoking b-gives advice and does not facilitate clients feelings d-does not facilitate clients feelings

A client receiving a tricyclic antidepressant arrives at the mental health clinic. Which observation indicates that the client is correctly following the medication plan? a. Reports not going to work for this past week b. Complains of not being able to "do anything" anymore c. Arrives at the clinic neat and appropriate in appearance d. Reports sleeping 12 hours per night and 3 to 4 hours during the day.

c. Arrives at the clinic neat and appropriate in appearance

A client is admitted to the psychiatric unit after a serious suicidal attempt be hanging. The nurse's most important aspect of care is to maintain client safety and plans to: a. Request that a peer remain with the client at all times b. Remove the client's clothing and place the client in a hospital gown. c. Assign a staff member to the client who will remain with him or her at all times. d. Admit the client to a seclusion room where all potentially dangerous articles are removed

c. Assign a staff member to the client who will remain with him or her at all times.

A nurse is preparing a client for the termination phase of the nurse-client relationship. Which nursing task would the nurse appropriately plan for this phase? a. Plan short term goals b. Identify expected outcomes. c. Assist in making appropriate referrals d. Assist in developing realistic solutions.

c. Assist in making appropriate referrals Why? a,b, & d are working phase of the relationship

A client was admitted to a medical unit with acute blindness. Many tests are performed and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit and run car crash, in which a family of three was killed. The nurse suspects that the client may be experiencing a: a. Psychosis b. Repression c. Conversion disorder d. Dissociative disorder

c. Conversion disorder Why? Conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. a-Psychosis is a state in which a person's mental capacity to recognize reality is impaired b-Repression is a coping mechanism in which unacceptable feelings are kept out of awareness d-Dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory or consciousness

A nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? (Select all that apply) a. Discourage reminiscing b. Make the decisions for the family c. Encourage expression of feelings, concerns and fears d. Explain everything that is happening to all family members e. Extend touch and hold the client's or family member's hand if appropriate f. Be honest and truthful and let the client and family know that you will not abandon them.

c. Encourage expression of feelings, concerns and fears e. Extend touch and hold the client's or family member's hand if appropriate f. Be honest and truthful and let client and family know that you will not abandon them.

A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client's efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis? a. Identifying the client's ability to function b. Identifying the client's potential for self- harm c. Inquiring about the client's feelings that may affect coping d. Inquiring about the client's perception of the cause of the neighbor's death

c. Inquiring about the client's perception of the cause of the neighbor's death. Why? The client must deal with feelings and neg. responses before the client is able to work through the meaning of the crisis. c- pertains direct to pt. feelings. a,b & d- do not directly address the clients feelings.

A nursing student is developing a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which incorrect intervention in the plan? a. Monitor intake and output b. Monitor electrolyte levels c. Observe for excessive exercise d. Monitor for the use of laxatives and diuretics.

c. Observe for excessive exercise Why? this is a characteristic of anorexia not bulimia 'incorrect' indicates a negative event a, b, & d are all alike. They all interfere with fluid and electrolyte balance.

A nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by: a. Engaging in immoral acts b. Always reinforcing self-approval c. Observing rigid rules and regulations d. Having the need to always make the right decision.

c. Observing rigid rules and regulations Why? Rules and rituals help the client manage their anxiety In the question it states 'manage anxiety' a-is not character of anorexia b & d is eliminated because the word 'always' (This is a close ended word)

A client arrives at the health care clinic and tells the nurse that he has been doubling his daily dosage of bupropion hydrochloride (Wellbutrin) to help him get better faster. The nurse understands that the client is now at risk for which of the following? a. Insomnia b. Weight gain c. Seizure activity d. Orthostatic hypotension

c. Seizure activity

A nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. The appropriate nursing intervention is which of the following? a. Ask direct questions to encourage talking. b. Leave the client alone and intermittently check on him c. Sit beside the client in silence and verbalize occasional open-ended questions. d. Take the client into the dayroom with other clients so they can help watch him.

c. Sit beside the client in silence and verbalize occasional open-ended questions. Why? 'therapeutic communication' a-asking direct questions is not therapeutic b-you never leave client alone d-you would never ask other clients to be responsible to another.

A nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse understands that these types of delusions are characteristic of which of the following? a. The false belief that one is a very powerful person b. The false belief that one is a very important person c. The false belief that one is being singled out of harm by others d. The false belief that one's partner is going out with other people.

c. The false belief that one is being singled out of harm by others. Why? A delusion is a false belief held to be true even when there is evidence to the contrary a & b A delusion of grandeur is the false belief that he or she is a very powerful and important person d-A delusion of jealousy is a false belief that one's partner is going out with other people plus eliminate a & b because they are alike. then single out 'delusions' to pick from the remaining 2

A nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client state: a. "My medications won't make me anxious." b. I'll go to a support group and talk so that I won't hurt anyone." c. "I won't get anxious or hear things if I get enough sleep and eat well." d. "I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone."

d. "I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone." Why? Talking about auditory hallucinations can interfere with the subvocal muscular activity associated with hallucination. Also it is evidence that they will seek help. 'command hallucinations' in the question and the correct option b- is not correct because the support group might not be at the same time client is having 'command hallucination' therefore will not be therapeutic.

A client is admitted to the in patient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse makes which therapeutic response? a. "It sounds as though you need to speak to the psychiatrist." b. "Perhaps you'd like to see the ECT room and speak to the staff." c. "Your child has decided to have this treatment. You should be supportive of the decision." d. "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

d. "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?" Why? it is the only option that encourage's the family a, b & c- avoid dealing with the client or family concerns

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client? a. "Have you talked to your family about this?" b. "Everyone feels this way when they are depressed." c. "You will feel better once your medication begins to work." d. "You sound very upset. Are you thinking of hurting yourself?"

d. "You sound very upset. Are you thinking of hurting yourself?"

A nurse is assisting in developing a plan of care for the client in a crisis state. When developing the plan, the nurse will consider which of the following? a. A crisis state indicates that the individual is suffering from a mental illness. b. A crisis state indicates that the individual is suffering from an emotional illness c. Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis. d. A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

d. A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse would encourage the client to attend which of the following community groups? a. Al-Anon b. Fresh Start c. Families Anonymous d. Alcoholics Anonymous

d. Alcoholics Anonymous

A nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse avoids which intervention in the plan of care? a. Facing the client when providing are b. Ensuring that a security officer is within the immediate area c. Keeping the door to the client's room open when with the client. d. Assigning the client to a room at the end of the hall to prevent disturbing the other clients

d. Assigning the client to a room at the end of the hall to prevent disturbing the other clients.

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as: a. Normal b. Regression c. Indicative of the client's ambivalence d. Evidence of the client's altered and distorted body image.

d. Evidence of the client's altered and distorted body image 'distorted body image'

Following a group therapy session, a client approaches the licensed practical nurse (LPN) and verbalizes a need for seclusion because of uncontrollable feelings. The LPN reports the findings to the RN and expects that the RN will take which of the following actions? a. Call the client's family b. Place the client in seclusion immediately c. Inform the client that seclusion has not been prescribed d. Get a written prescription from the health care provider (HCP) and obtain an informed consent.

d. Get a written prescription from the health care provider (HCP) and obtain an informed consent. Seclusion and restraint is permitted only on written prescription of HCP

A nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse monitors for which of the following? a. Hypotension, ataxia, vomiting b. Stupor, agitation, muscular rigidity c. Hypotension, bradycardia, agitation d. Hypertension, disorientation, hallucinations

d. Hypertension, disorientation, hallucinations Why? symptoms include anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, agitation, fever and delusions a & c are out because it is Hypo b. 'Stupor' not likely to feel agitation

A nurse is caring for a client with a diagnosis of depression. The nurse monitors signs of constipation and urinary retention, knowing these problems are likely caused by: a. Poor dietary choices b. Lack of exercise and poor diet c. Inadequate dietary intake and dehydration. d. Psycomotor retardation and side effects of medication

d. Psycomotor retardation and side effects of medication. Why? it addresses both concerns of constipation and urinary retention a, b & c- are all comparable or alike and only address diet

A nurse is assigned to care for a client at risk for alcohol withdrawal. The nurse monitors the client, knowing that the early signs of withdrawal will usually develop within how much time after cessation or reduction of alcohol intake? a. In 7 days b. In 14 days c. In 21 days d. Within a few hours

d. Within a few hours. with peak after 24-48 hours strategic word 'early'