Saunders Mental Health - Exam I

4 Aversion therapy provides a negative reinforcement when the stimulus is produced. The remaining options are characteristics of self-control therapy.

The client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1."This form of therapy can be applied to new situations." 2."An advantage of this technique is that change is likely to last." 3."Talking to oneself is a basic component of this form of therapy." 4."It provides a negative reinforcement when the stimulus is produced."

3 This question describes the victimized spouse of a perpetrator who uses multiple ways to control his victim. The correct option reflects and then provides an opportunity to share feelings. It is inappropriate for the nurse to chastise the client or respond in a sarcastic manner. It is nontherapeutic for the nurse to offer an observation that intellectualizes the situation since it does not facilitate the expression of feelings. Probing may cause the client to feel belittled.

A battered wife says, "My husband is a bully and a womanizer and certainly doesn't provide for his family, but he's never beat me up, so I don't think I can say he's abusive." Which response by the nurse is therapeutic? 1."Don't be so gullible. Your husband is an abuser." 2."How is it that he can maneuver you like he has?" 3."Do you believe that there are other forms of abuse besides the physical kind?" 4."Most emotionally battered spouses begin to heal once they start to identify the abusive behaviors."

2 The correct option addresses the subject of the client's statement. Avoid options that identify the process of agreeing with the client. The option of telling the client not to blame themselves is not directly related to the subject of the client's statement.

During a nursing interview, a client says, "My daughter was murdered. I can't help wondering if her husband killed her, but he's been eliminated as a suspect." Which statement is a therapeutic nursing response? 1."I agree. What do you want to bet he did it?" 2."Have you shared your concerns with the police?" 3."I don't think that you should blame yourself one little bit." 4."It feels terrible to lose a daughter. Your suspicions are only natural."

2 A compulsion is a repetitive act. The client with a phobia is likely to experience unreasonable fears. Illusions are characterized by misinterpretation of events. An obsession is a repetitive thought.

During an admission assessment, the nurse notes that the client's diagnosis is documented as obsessive-compulsive disorder. The nurse plans care knowing that the client is most likely to experience which type of compulsive behavior? 1.An unreasonable fear of something 2.Repetitive actions to manage anxiety 3.Misinterpretation of common events 4.Recurring thoughts that are intrusive

2 The question is focused on grieving. The only option that deals with grief is option 2. The information in the remaining options is not related to grief.

What is an appropriate short-term outcome for a client grieving the recent loss of a spouse? 1.The client reports 3 additional coping strategies. 2.The client verbalizes stages of grief and plans to attend a community grief group. 3.The client verbalizes connections between significant losses and low self-esteem. 4.The client verbalizes decreased desire for self-harm and discusses 2 alternatives to suicide.

2 The initial nursing assessment of a client in a crisis state is to evaluate the physical condition of the client, the potential for self-harm, and the potential for harm to others. Once this has been determined and appropriate interventions have been initiated, the nurse would then proceed with the mental health interview that involves the remaining options.

A client arrives in the emergency department in a crisis state demonstrating signs of profound anxiety. What should the initial nursing assessment focus on? 1.The object of the crisis 2.The client's physical condition 3.The client's coping mechanisms 4.The presence of support systems

1 Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment regardless of the client's willingness to consent to the hospitalization. A written request is a component of a voluntary admission. Providing written information regarding the mental health problem, is likely premature initially. The family may have had no role to play in the client's admission.

When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? 1.Monitor closely for harm to self or others. 2.Assist in completing an application for admission. 3.Supply the client with written information about her or his mental health problem. 4.Provide an opportunity for the family to discuss why they felt the admission was needed.

3 Nyctophobia is a fear of darkness. Social phobias are characterized by severe anxiety or fear provoked by exposure to a social situation or a performance situation. Fear of public speaking is the most common social phobia. Agoraphobia is a fear of open spaces. Claustrophobia is a fear of closed places.

Which behavior would the nurse anticipate a client diagnosed with nyctophobia to demonstrate? 1.Declines an invitation to walk around the park 2.Never takes an elevator but rather climbs the stairs 3.Always turns on the overhead light before entering a darkened room 4.Refuses to engage in conversations when in the presence of more than 2 to 3 people

4 During crisis counseling, the best approach for the nurse to use is an active one, with a focus on the current situation. The remaining options would be inconsistent with the acute needs that emerge in a crisis. Passive listening would be contrary to the individual's acute stress and disorganization. Exploring the past would be insensitive to the current crisis and would be exploitative of a client in acute distress. Although reassurance may be needed, what is most important about the nurse's response in a crisis is the need for a direct focus on immediate needs.

Which is the best therapeutic approach for the nurse to use in crisis counseling? 1.Reassuring 2.Passive listening 3.Exploration of early life experiences 4.Active, with focus on the current situation

4 The best responses to a client or family member who is visibly anxious and upset are those that use therapeutic communication techniques. Therapeutic communication includes active collaboration that facilitates problem solving, change, learning, and growth. The correct option addresses the daughter's concerns while upholding the dignity of the client. When these concerns are verbalized, the nurse can then give information that may help allay fears. None of the remaining options provide such support to the daughter.

A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). While the client is calm, the daughter anxiously tells the nurse, "My mother's brain will be shocked with electricity. How can the doctor even think about doing this to her?" Which response by the nurse will best address the daughter's concerns? 1."I think you need to speak directly to the psychiatrist." 2."Maybe you'll feel better if you see the ECT room and speak to the staff." 3."Your mother has decided to have this treatment. You should support her." 4."It sounds as though you are very concerned. Let's discuss the procedure."

2 In general, clients seek voluntary admission. Voluntary clients have the right to demand and obtain release. The nurse needs to be familiar with the state and facility policies and procedures. The initial nursing action is to contact the PHCP, who has the authority to discuss discharge with the client. While arranging for safe transportation is appropriate, it is premature in this situation and should be done only with the client's permission. While it is appropriate to discuss why the client feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the client to agree to staying "for only a few more days" has little value and will not likely be successful. Many states require that the client submit a written release notice to the facility psychiatrist, who reevaluates the client's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat with the client.

A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? 1.Call the client's family to arrange for transportation. 2.Contact the client's primary health care provider (PHCP). 3.Attempt to persuade the client to stay "for only a few more days." 4.Tell the client that leaving would likely result in an involuntary commitment.

1 In general, clients seek voluntary admission. Voluntary clients have the right to demand and obtain release, unless they pose an immediate danger to themselves or others, in which case the admission could become involuntary depending on the circumstances and regulations in that area and facility. The nurse needs to be familiar with the state and facility policies and procedures. The initial nursing action is to contact the PHCP, who has the authority to discuss discharge with the client. While arranging for safe transportation is appropriate, it is premature in this situation and should be done only with the client's permission. While it is appropriate to discuss why the client feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the client to agree to staying "for only a few more days" has little value and will not likely be successful. Many states require that the client submit a written release notice to the facility psychiatrist, who reevaluates the client's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat with the client.

A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action should the nurse take initially? 1.Contact the client's primary health care provider (PHCP). 2.Call the client's family to arrange for transportation. 3.Attempt to persuade the client to stay "for only a few more days." 4.Tell the client that leaving would likely result in an involuntary commitment.

1 If left alone, the severely anxious client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with the client. Teaching the client deep breathing or relaxation is not possible until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.

A client comes into the emergency department in a severe state of anxiety after a car crash. Which is the best nursing intervention at this time? 1.Remain with the client. 2.Put the client in a quiet room. 3.Teach the client deep breathing. 4.Encourage the client to talk about his or her feelings and concerns.

3 This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client's level of anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1.Begin to teach relaxation techniques. 2.Encourage the client to discuss the assault. 3.Remain with the client until the anxiety decreases. 4.Place the client in a quiet room alone to decrease stimulation.

1 Buspirone may be administered without regard to meals, and the tablets may be crushed. Mixing the tablet uncrushed in apple sauce will not ensure ease in swallowing. This medication is not available in liquid form. It is premature to advise the client to call the primary health care provider (PHCP) for a change in medication without first trying alternative interventions.

A client diagnosed with an anxiety disorder is prescribed buspirone orally. The client tells the nurse that it is difficult to swallow the tablets. Which is the best instruction to provide the client? 1.Crush the tablets before taking them. 2.Mix the tablet uncrushed in apple sauce. 3.Purchase the liquid preparation with the next refill. 4.Call the primary health care provider for a change in medication.

3 Lorazepam is a benzodiazepine and is contraindicated in hypersensitivity, cross-sensitivity with other benzodiazepines, comatose state, preexisting central nervous system depression, uncontrolled severe pain, and narrow-angle glaucoma because these medications can further increase the intraocular pressure. It also is contraindicated in pregnancy and in women who are breast-feeding. None of the other options are relevant to the administration of lorazepam.

A client diagnosed with anxiety is starting therapy with lorazepam. Which factor in the client's history should prompt the nurse to consult with the primary health care provider before administering the medication? 1.Hypothyroidism 2.Diabetes mellitus 3.Narrow-angle glaucoma 4.Coronary artery disease

1 Clients who are depressed may be at higher risk for suicide. When clients make statements such as the one in the question, it is critical for the nurse specifically to assess suicidal ideation and plan. The best method is to ask the client directly about whether a specific plan has been formed. The incorrect options either do not address the client's concern or place the client's feelings on hold.

A client diagnosed with depression says to the nurse, "Things would be so much better for everyone if I just weren't around." Which response should the nurse make at this time to assess the client's state of mind? 1."You sound very unhappy. Are you thinking of harming yourself?" 2."Have you talked to anyone specifically about what is bothering you?" 3."Those feelings will go away when your medication really takes effect." 4."I know what you mean; everyone gets that way when they are depressed."

3 Restating is a therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. Although it is appropriate for the nurse to attempt to assess the client's ability to discuss feelings openly with family members, it does not help the client discuss the feelings causing the anger. The nurse's direct attempt to expect the client to talk more about the anger is premature. The nurse would never make a judgment regarding the reason for the client's feeling; this is nontherapeutic in the one-to-one relationship.

A client diagnosed with terminal cancer 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." Which response by the nurse is therapeutic? 1."Have you shared your feelings with your family?" 2."I think we should talk more about your anger with your family." 3."You're feeling angry that your family continues to hope for you to be cured?" 4."You are probably very depressed, which is understandable with such a diagnosis."

3 Restating is a therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. While it is appropriate for the nurse to attempt to assess the client's ability to discuss feelings openly with family members, it does not help the client to discuss the feelings causing the anger. The nurse's direct attempt to expect the client to talk more about the anger is premature. The nurse would never make a judgment regarding the reason for the client's feeling; this is nontherapeutic in the one-to-one relationship.

A client diagnosed with terminal cancer 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." Which response by the nurse is therapeutic? 1."Have you shared your feelings with your family?" 2."I think we should talk more about your anger with your family." 3."You're feeling angry that your family continues to hope for you to be cured?" 4."You are probably very depressed, which is understandable with such a diagnosis."

4 Negative reinforcement when the stimulus is produced is descriptive of aversion therapy. Options 1, 2, and 3 are characteristics of self-control therapy.

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1."This form of therapy can be applied to new situations." 2."An advantage of this technique is that change is likely to last." 3."Talking to oneself is a basic component of this form of therapy." 4."This form of therapy provides a negative reinforcement when the stimulus is produced."

1 Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client-centered intervention. The remaining options are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior.

A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 1.Using open-ended questions and silence 2.Sharing personal preference regarding food choices 3.Documenting reasons why the client does not want to eat 4.Offering opinions about the necessity of adequate nutrition

1 Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client-centered intervention. The remaining options are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior.

A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 1.Using open-ended questions and silence 2.Sharing personal preferences regarding food choices 3.Documenting reasons why the client does not want to eat 4.Offering opinions about the necessity of adequate nutrition

4 Clomipramine is a tricyclic antidepressant used to treat obsessive-compulsive disorder. Sedation sometimes occurs. Insomnia seldom is a side effect. Weight gain and tachycardia are side and adverse effects of this medication.

A client gives the home health nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication? 1.Complaints of insomnia 2.Complaints of hunger and fatigue 3.A pulse rate less than 60 beats per minute 4.Frequent hand washing with hot, soapy water

2,3 If a client experiences anxiety, immediate actions are to provide a calm environment, decrease environmental stimuli, and stay with the client. Excess stimulation would escalate the anxiety. Next, asking the client to identify what and how he or she feels and helping the client to identify the causes of the feelings increase the client's awareness of the connection between behaviors and feelings. This awareness helps to decrease the anxiety. While listening to the client, the nurse observes for expressions of helplessness and hopelessness that could indicate self-harm intentions. The nurse provides follow-up care as needed, based on observations and assessments. Finally, the nurse documents the event, significant information, actions taken and follow-up actions, and the client's response. Turning the TV on ignores the client's feelings and increases stimuli. Leaning casually against the wall with the arms crossed presents a defensive stance.

A client is experiencing anxiety about being hospitalized. What therapeutic communication techniques should the nurse use while interacting with the client? Select all that apply. 1.Turn the client's favorite TV show on. 2.Ask the client to identify how he or she feels. 3.Help the client identify the cause of the anxiety. 4.Lean against the wall casually with arms crossed.

3 It is most therapeutic for the nurse to empathize with the client's experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.

A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? 1."I don't believe this is true." 2."The guards are not out to kill you." 3."Do you feel afraid that people are trying to hurt you?" 4."What makes you think the guards were sent to hurt you?"

3 The correct option explores the client's thoughts and feelings directly and fully. At the same time, it conveys an unhurried, nonjudgmental, and supportive attitude that is therapeutic. The client needs reassurance that these feelings are normal and may be expressed in this safe care environment. Avoid any option that places the client's feelings on hold, blocks further communication, or is likely to increase the client's fear.

A client states that she was raped a few weeks ago but still feels "as if it just happened to me." Which response should the nurse make to the client? 1."It is very, very hard to get over these types of feelings after being raped." 2."What do you think you should do to reduce the likelihood that you will be raped again?" 3."Tell me more about what happened and what causes you to feel like the rape just occurred." 4."It's hard, but try to keep a sense of perspective. After all, it's been a while since the rape occurred."

4 Depressed clients frequently exhibit feelings of low self-esteem and worthlessness. An effective plan of care should be designed for the client to provide experiences that are challenging but successful to enhance the client's self-esteem. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. The nurse should not devalue the client's feelings or challenge the client statements. The nurse should not focus on oneself.

A client states to the nurse, "My life has been such a failure. Nothing I do turns out right." Which response by the nurse will best address the client's low sense of self-esteem? 1."You can't really believe that about yourself." 2."I know just how you feel. I have those days myself once in a while." 3."I disagree with you; we all have some value and accomplishments in life." 4."You seem very discouraged. Let's identify something that you are proud of doing."

2 Buspirone is not recommended for the treatment of paranoid thought disorders, drug or alcohol withdrawal, or schizophrenia. Buspirone most often is indicated for the treatment of anxiety.

A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? 1.Paranoid thought process 2.Rapid heartbeat or anxiety 3.Alcohol withdrawal symptoms 4.Thought broadcasting or delusions

2 Clients who have learned that they have a chronic illness may exhibit denial, anger, or sarcasm because of fear associated with the chronic illness. It is important for the nurse to convey an accepting attitude to enhance mutual respect and trust. Eliminate options that are sarcastic or punitive. The only correct option is the one that respectfully addresses the concern presented by the client.

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic? 1."Do you think that having asthma will kill you?" 2."You seem very distressed over learning you have asthma." 3."Asthma is a treatable condition when medications are taken properly, so let's practice with your inhalant." 4."It will be difficult to work with you if you can't view this as a challenge rather than a nail in your coffin."

2 The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is the one that attempts to translate words into feelings. None of the remaining options encourage the client to discuss feelings but rather minimize and/or trivialize the feelings expressed.

A client who has recently lost her spouse says, "No one cares about me anymore. All the people I loved are dead." Which response demonstrates an understanding of therapeutic communication when dealing with a grieving client? 1."I certainly care about you." 2."You must be feeling all alone at this point." 3."I don't believe that and neither should you." 4."It isn't unusual to feel alone when you are grieving."

1 In the correct option, the nurse reflects back to the client what she is verbalizing and assists her to assess coping strategies. It is nontherapeutic for the nurse to change the focus from the client's expression of feelings related to the benzodiazepine. Asking the client to self-assess her own behavior in events is premature.

A client who is recovering from benzodiazepine dependence says, "I've lost so many people. First, my brother dies of cancer; then my husband leaves me for a 20-year-old. I wish I had 1 of those pills right now." Which statement by the nurse would be therapeutic? 1."Can you tell me what you think the pills can do for you?" 2."It sounds as if you feel that all of this has just happened to you." 3."It must have been a terrible loss for you when your brother died." 4."How did your husband's interest in a younger woman make you feel?"

2 The therapeutic statement is the one that gives the client permission to grieve and acknowledges that anger is part of loss and that it may be aimed at the people who are trying most to help and are closest. The remaining options are all nontherapeutic. They do not encourage the client to express feelings.

A client whose spouse of 42 years recently died shares with the nurse, "My sister came over yesterday and started talking about how I need to move on with my life. I feel badly, but I got mad and told her to mind her own business." Which response by the nurse would be therapeutic? 1."I know just how you feel; I lost my husband last summer." 2."You need to grieve, and expressing anger can be part of grieving." 3."Although she means to help, you need to do what feels right for you." 4."Focusing on the many good years you both enjoyed together will help."

2 The therapeutic nursing response is the one that recognizes the difficulties of grieving the loss of a loved one and that facilitates expression of feelings. The remaining options are not therapeutic because they do not encourage expression of feelings.

A client whose wife recently died of cancer says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house." What is the therapeutic nursing response? 1."It will take time to adjust to your terrible loss." 2."It must be hard to accept that she has passed away." 3."Try to focus on the fact that you and your wife loved one another for years." 4."Focus on the fact that her suffering is over and that she had a good life with you."

4 Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. The remaining options block communication because they minimize the client's experience and do not facilitate exploration of the client's expressed feelings. In addition, use of the word why is nontherapeutic because clients frequently interpret why questions as accusations. Why questions can cause resentment, insecurity and mistrust.

A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response by the nurse demonstrates therapeutic communication? 1."You have everything to live for." 2."Why do you see yourself as a failure?" 3."Feeling like this is all part of being depressed." 4."You've been feeling like a failure for a while?"

2 In the first phase of the crisis response, the client implements usual coping methods to bring about relief from the problem and shows signs of anxiety when these methods are failing. The second phase of crisis response involves a redefining of the threat or implementation of new coping methods that can result in resolution of the problem. If resolution does not occur in the second phase, the client progresses to severe or panic levels of anxiety reflective of the third phase of the response.

A client with a history of anxiety appears to be in the second phase of crisis response. The nurse prepares for which client behavior? 1.The client will show the initial signs that coping methods are failing. 2.The client will employ new coping methods that will resolve the problem. 3.The client will experience severe anxiety as a result of failed coping methods. 4.The client will begin to implement coping methods that have been successful in the past.

1 Clients with panic disorders experience acute physical symptoms, such as chest pain and palpitations. The priority is to assess the client's physical condition to rule out a physiological disorder. Therefore, options 2, 3, and 4 are not the priority.

A client with a history of panic disorder comes to the emergency department and states to the nurse, "Please help me. I think I'm having a heart attack." What is the priority nursing action? 1.Assess the client's vital signs. 2.Identify the client's activity during the pain. 3.Assess for signs related to a panic disorder. 4.Determine the client's use of relaxation techniques.

3 An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. A client may have provided oral or written instructions regarding an autopsy after death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin.

A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate? 1."The decision is made by the medical examiner." 2."An autopsy is mandatory for any client who is DOA." 3."I will contact the medical examiner regarding your request." 4."It is required by federal law. Tell me why you don't want the autopsy done."

4 Systematic desensitization is a form of therapy in which the client is introduced to short periods of exposure to the phobic object while in a relaxed state. Gradually, over a period of time, exposure is increased until the anxiety about or fear of the object or situation has ceased. Medication is associated with pharmacological therapy. While stress management techniques and self-help groups may be helpful, neither is the basis of this therapy.

A client's phobia is being treated with systematic desensitization. Which modality is the focus of this therapy? 1.Daily medication therapy 2.Involvement with a support group 3.Intense stress management training 4.Short exposure to the phobic object

3 Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging, but that will not be met with failure. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. Options 1 and 2 give advice and devalue the client's feelings. Silence may be interpreted as agreement.

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan to respond to the client's statement? 1.Reassure the client that things will get better. 2.Tell the client that this is not true and that we all have a purpose in life. 3.Identify recent behaviors or accomplishments that demonstrate the client's skills. 4.Remain with the client and sit in silence; this will encourage the client to verbalize feelings.

3 The correct option allows the client to express her ideas and feelings more fully and portrays a nonhurried, nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment. Option 1 immediately blocks communication. Option 2 places the client's feelings on hold. Option 4 places the problem solving totally on the client.

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response? 1."You need to try to be realistic. The rape did not just occur." 2."It will take some time to get over these feelings about your rape." 3."Tell me more about the incident that causes you to feel like the rape just occurred." 4."What do you think that you can do to alleviate some of your fears about being raped again?"

3 The victims of community disaster are at a risk for stress-induced psychiatric crises. The needs of these individuals for food, clothing, and shelter should be addressed first to minimize the stress-producing effect these losses may have on the chronically mentally ill. Stress is a key factor in the relapse into crisis for these individuals. After these basic needs are met, the remaining options can then be implemented.

A homeless shelter has sustained severe damage as a result of a fire, and most of the structure and people's belongings were destroyed. Ten of the individuals who are being displaced have a history of chronic mental illness. The mental health team coordinating support initially should focus their efforts on which action? 1.Assessing the clients' need for supportive therapy 2.Evaluating the clients for signs of stress overload 3.Providing the clients with shelter, clothing, and food 4.Planning means for the clients to receive their medications

3 When delusional, a client truly believes what he or she thinks to be real is real. The client's thinking often reflects feelings of great fear and aloneness. It is most therapeutic for the nurse to empathize with the client's experience. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusions is inappropriate.

A hospitalized client experiencing delusions reports to the nurse, "I know that the doctor is talking to the top man in the mob to get rid of me." Which response should the nurse make to the client? 1."I don't believe this is true." 2."The doctor is not talking to the mob." 3."Do you feel afraid that people are trying to hurt you?" 4."What makes you think the doctor wants to get rid of you?"

3 Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the entire surgical procedure may increase the client's anxiety. Option 4 avoids the client's anxiety and is focused on postoperative care.

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1."If it's any help, everyone is nervous before surgery." 2."I will be happy to explain the entire surgical procedure to you." 3."Can you share with me what you've been told about your surgery?" 4."Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

1 A client with severe anxiety may feel abandoned and become overwhelmed if left alone. Placing the client in a quiet room is also indicated, but it is more important to stay with the client. The client may not feel comfortable being located a distance from other people. It is not realistic to teach the client deep breathing or relaxation until the anxiety decreases. Encouraging the client to share feelings would be appropriate after anxiety has decreased.

A woman is seen in the emergency department in a severe state of anxiety following assault and battery. Which nursing action should the nurse place highest priority on at this time? 1.Remaining with the client 2.Teaching the client deep-breathing techniques 3.Encouraging the client to talk about her feelings 4.Putting the client in a quiet room, away from other clients

2 An anxious client benefits from emotional support and reassurance, which in turn reduces anxiety and may lower the respiratory rate. The client may benefit from the administration of a sedative or antianxiety medication if it is prescribed. The client should try to breathe more slowly. Lying supine provides no benefit to the client and may cause problems with breathing.

An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse should take which action to help the client experiencing this acid-base disorder? 1.Put the client in a supine position. 2.Provide emotional support and reassurance. 3.Withhold all sedative or antianxiety medications. 4.Tell the client to breathe very deeply but more slowly.

4 Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth, headache, lightheadedness, vertigo, mental status changes, paresthesias such as tingling of the fingers and toes, hypokalemia, hypocalcemia, tetany, and convulsions. The remaining three options are not clinical manifestations of respiratory alkalosis.

An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1.Headache and tachypnea 2.Hyperactivity and dyspnea 3.Muscle twitches and cyanosis 4.Lightheadedness and paresthesias

4 The correct response acknowledges the client's comment and behavior. Allowing the client to leave after forms are signed fails to protect the client from possible harm. The remaining options do not preserve the client's dignity.

An older resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." Which is the appropriate response by the nurse? 1."I need you to sign a form before leaving." 2."You will get sick if you go out in the rain." 3."How old are you? Your father must no longer be living." 4."Let's have a cup of coffee, and you can tell me about your father."

2 Buspirone hydrochloride is an anxiolytic medication. Dizziness, nausea, headaches, nervousness, lightheadedness, and excitement, which generally are not major problems, are side effects. Buspirone hydrochloride is not addicting, tolerance does not develop, and it is not sedating.

Buspirone hydrochloride is prescribed for a client with an anxiety disorder. The nurse plans to include which teaching point when reviewing this medication with the client? 1.The medication is addicting. 2.Dizziness and nervousness may occur. 3.Tolerance can develop with this medication. 4.The medication can produce a sedating effect.

2,4,5 Multiple personality disorder is considered to be a dissociative disorder rather than an anxiety disorder. Anxiety is a characteristic of panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder. Dementia may or may not be associated with anxiety.

Clients with which diagnoses are commonly prescribed interventions to manage anxiety? Select all that apply. 1.Dementia 2.Panic disorder 3.Multiple personality disorder 4.Post-traumatic stress disorder 5.Obsessive-compulsive disorder

3 This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is critical for the nurse to remain with the client. The client in a severe state of anxiety would not be able to learn relaxation techniques. Processing the experience at this point will further increase the client's level of anxiety.

Immediately after an assault, the client is extremely agitated, trembling, and hyperventilating. What is the appropriate initial nursing action? 1.Begin to teach relaxation techniques. 2.Encourage the client to discuss the assault. 3.Remain with the client until the anxiety decreases. 4.Place the client in a quiet room alone to decrease stimulation.

4 The correct option helps the client focus on the emotion underlying the delusion but does not argue with it. Avoid statements that place the client in a position that requires a response. Attempting to avoid the situation will not address the client's anxiety. The incorrect responses may cause the client to hold the delusion more strongly.

Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of blood, the client begins to shout, "You're all vampires. Let me out of here!" Which nursing response addresses the client's anxiety? 1."What makes you think that I am a vampire?" 2."I'll leave and come back later for the specimen." 3."Do you remember discussing the lab work earlier?" 4."It must be frightening to think that others want to hurt you."

4 Rationale:In general, clients seek voluntary admission. If a client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program since she or he is actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee that a client understands her or his mental health problem, only the client's desire for help.

On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior? 1.Fearfulness regarding treatment measures 2.Anger and aggressiveness directed toward others 3.An understanding of the pathology and symptoms of the diagnosis 4.A willingness to participate in the planning of the care and treatment plan

3 The client who has severe anxiety has significant somatic complaints, ineffective functioning, loud or rapid speech, and purposeless activity. Option 1 describes fear and paranoia. Option 2 is characteristic of a withdrawn client or a client with depression. Option 4 describes a panic state. Panic is associated with a feeling of dread and terror and a sense of impending doom.

Soon after an assault, a client is assessed in the emergency department with behavior that is associated with severe anxiety. Which client behaviors support this level of anxiety? 1.Believes the attacker is in the emergency department 2.Detached, requiring gentle probing to respond to questions 3.Is pacing while describing the situation using a rapid speech pattern 4.Talks about being "panic stricken" that something else "bad" will happen

4 The nurse should become aware of the client's strengths and encourage the client to work at the optimal level of functioning. In the correct option, the nurse is helping the client develop resources. The nurse does not act for clients unless absolutely necessary and then only as a step toward helping them act on their own. Consistently encouraging clients to use their own resources helps minimize their feelings of helplessness and dependency and also validates their potential for change.

The client asks the nurse, "Could you ask my psychiatrist to let me have a pass for the weekend?" Which response is appropriate and assists the client in achieving the goal of optimal personal functioning? 1."You have to ask your psychiatrist for the pass; I can't get it for you." 2."When your psychiatrist comes in, I will ask for a pass for the weekend." 3."You are not ready for such a pass, and I'm sure that your psychiatrist will say no." 4."When your psychiatrist arrives on the unit, I will let them know that you have a question."

2 Nurses may struggle with requests by clients to "be my friend." When this occurs, the nurse should make it clear that the relationship is a therapeutic and helping one. This does not mean that the nurse is not friendly toward the client at times. It does mean, however, that the nurse follows the stated guidelines regarding a therapeutic relationship. The remaining options are inappropriate, particularly in their failure to define the relationship.

The client says to the nurse, "I wish you would just be my friend." Which is the appropriate response by the nurse? 1."I am your friend." 2."Our relationship is a therapeutic and helping one." 3."I can't be your friend. I'm the nurse, and you're the client." 4."You have plenty of friends. You don't need me to be your friend, too."

4 A repetitive behavior that interferes with activities of daily living and functioning is indicative of obsessive-compulsive disorder (OCD). This repetitive behavior is not associated with phobias, generalized anxiety disorder, or post-traumatic stress disorder.

The client tells the nurse that she cannot leave home without checking numerous times that "everything electrical has been shut off." The client's statement supports which mental health diagnosis? 1.A phobia 2.Generalized anxiety disorder 3.Post-traumatic stress disorder 4.Obsessive-compulsive disorder

4 It is important for the nurse to let the client know that what the client is hearing is not heard by the nurse and to avoid reinforcing the client's altered reality. The nurse should avoid confronting the client. The nurse should say supportive things such as, "This must be very frightening to you" or "It's difficult to understand all that you are experiencing right now." The remaining options reinforce the client's altered reality.

The client who is actively hallucinating is fearful that the voices will direct him to kill himself. Which therapeutic statement should the nurse make at this time? 1."I can hear the voices too, but ignore them and just go to bed now." 2."I know whose voices you are hearing, and I told them not to hurt you." 3."I know you believe they are going to cause you harm, but it's not true." 4."I don't hear them, but it must be frightening to hear voices that others can't hear."

2,3,4,5 Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. Neglecting personal grooming is indicative of a behavior that identifies ineffective coping in the grieving process. The remaining options identify appropriate and effective coping mechanisms.

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicate effective coping? Select all that apply. 1.Neglecting personal grooming 2.Looking at old photographs of family 3.Participating in a senior citizens program 4.Visiting the spouse's grave once a month 5.Decorating a wall with the spouse's pictures and awards received

4 Generalizing fears to a specific place or situation is the hallmark of agoraphobia. Improvement is observed when the client is able to demonstrate appropriate coping behaviors for anxiety reduction. Taking extra anxiety medication would not indicate improvement. "Clock-watching" with regard to the medication schedule is also not a sign that the client is responding well to the treatment.

The home health nurse visits an agoraphobic client who experiences panic attacks. Which statement by the client would indicate a therapeutic response to behavioral and pharmacological treatment? 1."I took an extra pill for anxiety and got through the funeral fairly well." 2."I worry that if I don't take my anxiety pill on time, I'll have one of those attacks." 3."Taking my anxiety pills before I leave has helped me to cross the bridge and go to work every morning." 4."I went to the movies with my family and stayed through the whole film by sitting in a seat along the aisle."

3 This question describes the husband of an alcohol-dependent wife who is developing awareness of his codependency. Codependency consists of an individual's becoming preoccupied with the needs and concerns of another to the exclusion of his or her own needs. The therapeutic statement seeks clarification and summarizes and focuses the client on his own concerns and discoveries. When the nurse provides a social response that is nontherapeutic, it does not focus on the client's feelings. Intellectual questioning does not facilitate expression of feelings. Asking questions that are off-focus from the client's feelings are nontherapeutic because they constitute probing. The nurse will gather this information, but by gaining the trust of the client, not by probing.

The husband of an alcohol-dependent wife says, "If anyone had said I'd be henpecked, I'd have called them a liar, but now I realize that I'm codependent." Which statement by the nurse would be therapeutic? 1."Did you know that more people identify with just what you are saying?" 2."Which of the features that describe codependence caused you to recognize that?" 3."Can you tell me more about that? You see yourself as being codependent with your wife?" 4."Have you discussed your feelings with your wife? What does your wife think about what you've said?"

3 It is recommended that clients with anxiety disorder abstain from or limit their intake of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety. Restricting interactions with friends and keeping the daughter out of school are unreasonable and unhealthy approaches. It may not always be realistic to expect a family member to take time off from work.

The mother of a teenage client states that her daughter, diagnosed with an anxiety disorder, "eats nothing but junk food, has never liked going to school, and hangs out with the wrong crowd." What discharge instruction will be most effective in helping the mother to manage her daughter's condition? 1.Restrict the daughter's socializing time with her friends. 2.Keep her daughter out of school until her anxiety is well managed. 3.Restrict the amount of chocolate and caffeine products in the home. 4.Consider taking time off from work to help her daughter learn to manage the anxiety.

4 In obsessive-compulsive disorder (OCD), the rituals performed by the client are an unconscious response that helps to divert and control the unpleasant thought or feeling and prevent acting on it. This decreases the client's anxiety. OCD is not associated with a need for control or punishment, or with hallucinations.

The nurse determines that the client understands the basis of the diagnosis of obsessive-compulsive disorder after making which statement? 1."Inner voices tell me to perform my rituals." 2."My behavior is a conscious attempt to punish myself." 3."I'm demonstrating control when I engage in my rituals." 4."My rituals are ways for me to control unpleasant thoughts or feelings."

1 The nurse is required to maintain confidentiality regarding the client and the client's care. Confidentiality is basic to the therapeutic relationship and is a client's right. The most appropriate response to the neighbor is the statement of that responsibility in a direct, but polite manner. A blunt statement that does not acknowledge why the nurse cannot reveal client information may be taken as disrespectful and uncaring. The remaining options identify statements that do not maintain client confidentiality.

The nurse employed in a mental health clinic 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." Which is the most appropriate nursing response? 1."I cannot discuss any client situation with you." 2."If you want to know about Carol, you need to ask her yourself." 3."Only because you're worried about a friend, I'll tell you that she is improving." 4."Being her friend, you know she is having a difficult time and deserves her privacy."

2 Buspirone hydrochloride is most often indicated for the treatment of anxiety and aggression. It is not recommended for the treatment of thought disorders (delusions), drug or alcohol cravings, or schizophrenia (paranoid thoughts).

The nurse gathers data from the client who was prescribed buspirone hydrochloride 1 month ago. The nurse interprets that the medication is effective when the client reports an absence of which event? 1.Delusions 2.Severe anxiety 3.Alcohol cravings 4.Paranoid thoughts

2 During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate an expected reaction. Options 1, 3, and 4 are incorrect interpretations.

The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How should the nurse interpret these behaviors? 1.Signs of depression 2.Reactions to a devastating event 3.Evidence that the client is a high suicide risk 4.Indicative of the need for hospital admission

1,2,4,5 Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking "Why" is often interpreted as being accusatory by the client and should also be avoided. Providing advice or giving approval or disapproval are barriers to communication.

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. 1.Restating 2.Active listening 3.Asking the client "Why?" 4.Maintaining neutral responses 5.Providing acknowledgment and feedback 6.Giving advice and approval or disapproval

1,2,4,5 Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why is often interpreted as being accusatory by the client and should also be avoided. Providing advice or giving approval or disapproval are barriers to communication.

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. 1.Restating 2.Listening 3.Asking the client "Why?" 4.Maintaining neutral responses 5.Providing acknowledgment and feedback 6.Giving advice and approval or disapproval

4 The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating, not acidosis. Concluding that the client is overreacting is an inaccurate analysis. No conclusion can be made about a client's fluid volume status from the information provided.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm (72 mmol/L), and HCO3− = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? 1.The client has acidotic blood. 2.The client is probably overreacting. 3.The client is fluid volume overloaded. 4.The client is probably hyperventilating.

4 The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating, not acidosis. Concluding that the client is overreacting is an insufficient analysis. No conclusion can be made about a client's fluid volume status from the information provided.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mm Hg (32 mm Hg), and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? 1.The client has acidotic blood. 2.The client is probably overreacting. 3.The client is fluid volume overloaded. 4.The client is probably hyperventilating.

1 Agoraphobia is a fear of leaving the house and experiencing panic attacks when doing so. The remaining options describe obsessive-compulsive behavior, claustrophobia, and a social phobia.

The nurse is caring for a client with a diagnosis of agoraphobia. Which statement made by the client would support this diagnosis? 1."I'd be sure to have a panic attack if I left my house." 2."I couldn't touch a public doorknob unless I wore gloves." 3."Just the thought of getting into an elevator causes me to panic." 4."Speaking to more than 1 or 2 people would be impossible for me."

3 The client is experiencing loss because of the recent death of her husband and is expressing feelings of hopelessness. The therapeutic response by the nurse is the one that attempts to translate words into feelings. Communication would be discouraged by statements that deny the client's feelings or that do not address the client's concerns.

The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There is no one left who cares about me. Everyone that I have loved is now gone." Which nursing response allows for continued communication about the client's state of mind? 1."That doesn't sound like the real you talking!" 2."I'm sure you have someone if you think hard enough." 3."It sounds as though you are feeling all alone right now." 4."I don't believe that, and I really don't think you do either."

3 The nurse's initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. The correct option would assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 assess situational supports. Option 4 assesses personal coping skills.

The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? 1."With whom do you live?" 2."Who is available to help you?" 3."What leads you to seek help now?" 4."What do you usually do to feel better?"

4 Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one client may not constitute a crisis for another client because each is a unique individual. Being in the crisis state does not mean that the client has a mental or emotional illness.

The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 1.A crisis state indicates that the client has a mental illness. 2.A crisis state indicates that the client has an emotional illness. 3.Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. 4.A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

4 Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one client may not constitute a crisis for another client, because each is a unique individual. Being in the crisis state does not mean that the client has a mental or emotional illness.

The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 1.A crisis state indicates that the client has a mental illness. 2.A crisis state indicates that the client has an emotional illness. 3.Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. 4.A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

3 Lack of ability to cope effectively may be evidenced by a client's inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers; although the client was experiencing anxiety, the client's concern now is the ability to meet role expectations and financial obligations. There is no information in the question that indicates an unrealistic outlook or disturbances in thoughts and ideas.

The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? 1.Anxiety 2.Unrealistic outlook 3.Lack of ability to cope effectively 4.Disturbances in thoughts and ideas

4 The priority is to establish a trusting relationship with the client. Demanding anything from the client should never occur. The remaining options are appropriate components of the plan of care but are not the priority. A trusting nurse-client relationship needs to be established first.

The nurse is developing a plan of care for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. What is the nurse's priority in the plan of care? 1.Monitor for repetitive behavior. 2.Demand active participation in care. 3.Educate the client about self-care needs. 4.Establish a trusting nurse-client relationship.

1 Open-ended questions and silence are strategies used to encourage clients to discuss their feelings. None of the remaining options attempt to encourage communication with the client.

The nurse is developing a plan of care for a client who believes the unit's food is being poisoned. Which strategy should the nurse plan to implement that will encourage the client to discuss feelings? 1.Use open-ended questions and silence. 2.Encourage the client's family to bring in food. 3.Focus on the fact that the client's beliefs are untrue. 4.Instruct the client about the need for adequate nutrition.

2 The priority would be to develop individualized goals and objectives in the plan of care. Goals and objectives are a mutual working tool between the client and the nurse. Although the medical diagnosis of the client is considered in planning care, it is not specifically a component of a nursing care plan. Attendance at group therapy sessions and promotion of self-care measures may be components of the plan of care, but these interventions would follow after development of the goals and objectives.

The nurse is preparing to create a care plan for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. The nurse should plan to include which component as a priority in the plan of care? 1.The medical diagnosis of the client 2.Individualized goals and objectives 3.Attendance at group therapy sessions 4.Self-care measures to improve hygiene

2 A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster, is not a part of everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster (e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child abuse).

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? 1.Witnessing a murder 2.The death of a loved one 3.A fire that destroyed the client's home 4.A recent rape episode experienced by the client

4 The nurse who disagrees with a client's delusions may make the client more defensive and cling to the delusions even more firmly. It is most therapeutic for the nurse to empathize with the client's experience. The nurse can also use the opportunity to try to explore further the meaning of the experience for the client. The correct option presents reality to the client and then focuses on the client's feelings. None of the other options provide this support.

The nurse is working with a client who is demonstrating delusional thinking. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which is the best response by the nurse? 1."I don't believe that what you are telling me is true." 2."There are no religious cults in this area that are going to kill you." 3."What makes you think that cult members are being sent to hurt you?" 4."I don't know about a religious cult. Are you afraid that people are trying to hurt you?"

4 The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. The correct option pertains directly to the client's feelings and is client-focused. The remaining options do not directly focus on or address the client's feelings.

The nurse is working with a client who, despite making a heroic effort, was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? 1.Exploring the client's ability to function 2.Exploring the client's potential for self-harm 3.Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4.Inquiring about and examining the client's feelings for any that may block adaptive coping

4 Rigid and inflexible behaviors are characteristic of the client with obsessive-compulsive disorder (OCD). Clients with this disorder usually are not hostile unless they are prevented from engaging in the obsession or compulsion because this behavior is what decreases the anxiety. None of the other options are associated with OCD.

The nurse preparing to admit a client with a diagnosis of obsessive-compulsive disorder to the mental health unit should expect to note which behaviors in the client? 1.Sad and tearful 2.Suspicious and hostile 3.Frightened and delusional 4.Rigidness in thought and inflexibility

1,2,5 Maintaining effective and open communication among family members affected by death and grief is of the greatest importance. Option 1 describes encouraging discussion of feelings and is likely to enhance communication. Option 2 is also an effective intervention because spiritual practices give meaning to life and have an impact on how people react to crisis. Option 5 is also an effective technique because the client and family need to know that someone will be there who is supportive and nonjudgmental. The remaining options describe the nurse removing autonomy and decision making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. These are ineffective interventions that could impair communication further.

The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select all that apply. 1.The nurse encourages the client and family to identify and discuss feelings openly. 2.The nurse assists the client and family in carrying out spiritually meaningful practices. 3.The nurse removes autonomy from the client to alleviate any unnecessary stress for the client. 4.The nurse makes decisions for the client and family to relieve them of unnecessary demands. 5.The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

3 Anxiety signs and symptoms may take a physical form and if abnormal should be addressed as a priority for the client. A temperature of 98.4º F and respirations 18 breaths/min are normal vital signs. Tearfulness, self-isolation, a bland affect, and a withdrawn state are abnormal findings but are commonly associated with anxiety. These findings are not life threatening, although they should be monitored. Fist clenched, pounding the table, and exhibiting fear indicate a possible threat to safety of the client or others.

The nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse should assign priority to which assessment finding? 1.Tearful, self-isolated 2.Affect bland, withdrawn 3.Fist clenched, pounding table, fearful 4.Temperature 98.4º F (36.8º C); respirations 18 breaths/min

3 Clomipramine is an antidepressant that is commonly used in the treatment of obsessive-compulsive disorder. Frequent checking for the car key is a nonproductive repetitive activity that is characteristic of this disorder. Reappearance of symptoms may indicate noncompliance with medication therapy. The incorrect options are common side/adverse effects of the medication.

The nurse suspects that a client prescribed clomipramine hydrochloride has been noncompliant with taking the medication as prescribed. Which client behavior would support the nurse's suspicion? 1.Tired, fatigued appearance 2.Complaints of hunger and fatigue 3.Frequently checking for the car key 4.Slight dizziness when standing up quickly

2 The correct option encourages the client to socialize and indicates that it is not necessary to sing. Avoid the use of the word why since it can be insulting to the client. Don't make or imply a demand. Focus on addressing the client's concern. The correct option is the only one that addresses the client's concern.

The nurse tells the client that a music therapy session has been scheduled as part of the treatment plan. The client tells the nurse, "I can't sing," and refuses to attend. Which nursing response is most likely to meet the client's needs? 1."Why don't you want to attend? What is the real reason?" 2."You don't have to sing. Just listen and enjoy the music." 3."You must go. You have no choice if you want to get better." 4."Your primary health care provider has prescribed this therapy for you."

3 Rationale:The correct option uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client's major theme, which assists the nurse to obtain a more specific perception of the problem from the client. The remaining options are not therapeutic responses because none of them encourages the client to expand on the problem. Offering personal experiences moves the focus away from the client and onto the nurse.

The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? 1."I see." 2."Really?" 3."You're having difficulty sleeping?" 4."Sometimes I have trouble sleeping too."

3 The correct option uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client's major theme, which assists the nurse to obtain a more specific perception of the problem from the client. The remaining options are not therapeutic responses since none encourages the client to expand on the problem. Offering personal experiences moves the focus away from the client and onto the nurse.

The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? 1."I see." 2."Really?" 3."You're having difficulty sleeping?" 4."Sometimes I have trouble sleeping too."

3 The most helpful response is one that encourages the spouse to explore the problem and problem-solve. The correct response should not disregard or redirect focus away from the spouse's concern. The nurse should appear neither to disagree nor agree with the spouse. Giving advice implies that the nurse knows what is best and can also foster dependency.

The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which response by the nurse addresses the spouse's concerns? 1."This is not a good time to make that decision." 2."What would your spouse think about your decision?" 3."What aspects of this situation are the most difficult for you?" 4."You seem to have a good grip on this situation. You probably should get out."

2 In cognitive-behavioral therapy, the client with a phobia who experiences panic attacks will be treated with a combination of cognitive restructuring, exposure therapy, and paradoxical intention. In paradoxical intention the client is instructed to do what he fears and, if possible, to exaggerate it to the point of humor. When this occurs the client is taught to prevent the anxiety by a variety of coping mechanisms. This assists the client to regain an internal locus of control or feeling of empowerment and to master response to the anxiety-provoking issue or situation. Other options describe in vivo therapy, flooding, and systematic desensitization.

The psychiatric home care nurse visits a client diagnosed with a phobia that triggers panic attacks. When teaching the client to use paradoxical intention, which intervention will the nurse demonstrate? 1.Having the client confront the anxiety-provoking stimulus and providing support during the episode 2.Instructing the client to do what the client fears and, if possible, to exaggerate the outcome of this exposure to the point of humor 3.Presenting the anxiety-provoking stimulus without any preparation of the client and having him or her remain exposed until the anxiety subsides 4.Using progressive relaxation toward the client's individual anxiety hierarchy, increasing the level of difficulty, and pairing relaxation with the gradual exposure to reduce his or her anxiety

4 If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although telling the client to stop monopolizing in a firm but compassionate manner may be a direct response, the correct option is more specific and provides direction for the client. The remaining options are inappropriate because they are not directed toward helping the client in a therapeutic manner.

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1.Ask the client to leave the group for this session only. 2.Refer the client to another group that includes other manic clients. 3.Tell the client to stop monopolizing in a firm but compassionate manner. 4.Thank the client for the input, but inform the client that others now need a chance to contribute.

4 If a client consistently demonstrates a behavior, such as arriving late for a scheduled meeting, the nurse should explore the reason for the behavior with the client. Ignoring the behavior is not a therapeutic or helpful nursing action. Terminating the meeting is inappropriate. Behavior that is similar to the client's behavior is nontherapeutic and inappropriate. It is most helpful to the client for the nurse to explore the reasons for the client's behavior.

When a client is consistently 15 to 20 minutes late for weekly therapy sessions, the nurse attempts to best manage this behavior by implementing which intervention? 1.Ignoring the client's behavior 2.Telling the client that the sessions will be terminated 3.Arriving 15 minutes later than the scheduled time also 4.Asking the client if she or he is dealing with some new stressor

2 Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.

When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal? 1.Suppressing feelings of anxiety 2.Identifying anxiety-producing situations 3.Continuing contact with a crisis counselor 4.Eliminating all anxiety from daily situations

4 The primary goal of crisis intervention therapy is returning the client to a level of functioning that is equal to or better than that experienced precrisis. This goal is reached through strategies that include the introduction of new coping methods directed toward the stressors that contributed to the crisis. The establishment of a therapeutic nurse-client relationship is a general goal for all nursing relationships.

Which is the primary goal of crisis intervention therapy? 1.Introduce new, effective coping methods to the client. 2.Assess the client to identify the causative stressors. 3.Establish a sustainable therapeutic nurse-client relationship. 4.Assist the client in returning to the level of precrisis functioning.

2 The report that the client is doing well at work indicates a level of functioning amid stress that is at least equal to that of the precrisis period. Being told by her spouse that she is again cheerful is a positive improvement but is not indicative of general functioning. Being self-aware and recognizing the need to implement coping methods appropriately when stress triggers are present is a positive indicator of improvement, as is an improved sense of empowerment and confidence in handling problems, but neither indicates the true ability to successfully handle stress efficiently or the client's return to her precrisis level of functioning.

Which statement, made by a client who has recently experienced an emotional crisis, is most likely to assure the nurse that the client has returned to her precrisis level of functioning? 1."My husband tells me that I'm back to my old cheerful self." 2."My boss tells me that I'm being considered for a promotion and a raise." 3."When I find myself getting stressed, I immediately use the relaxation techniques I've learned." 4."I have a different perspective on life now. I'm more confident of my ability to handle any problem."