Unit 7 Flash

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 present at the time should respond by stating which?

"Are you fearful and think that others may want to hurt you?"

The 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 states which?

"I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone."

Ping-Pong

"I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?"

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 should be an appropriate choice as this client's roommate?

A client receiving diagnostic tests

Treatment that involves pairing a stimulus attractive to the client with an unpleasant event is known as which type of therapy?

Aversion therapy

The nursing student is asked to identify the characteristics of bulimia nervosa. Which response by the student indicates a need to further research of the disorder?

Body weight well below ideal range

The nurse collects data on a client with a diagnosis of bipolar affective disorder-mania. Which finding requires the nurse's immediate intervention?

Client's inadequate attention to activities of daily living (ADL) and poor nutritional intake

The nurse enters a client's room, and the client immediately demands to be released from the hospital. On review of the client's record, the nurse notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was a voluntary admission. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Contact the health care provider (HCP).

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 which?

Conversion disorder

In planning activities for the depressed client, especially during the early stages of hospitalization, which is best?

Encourage the client to participate in a structured daily program of activities.

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 which?

Evidence of the client's altered and distorted body image

A client experiencing a severe major depressive episode is unable to address activities of daily living. The appropriate nursing intervention is which?

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

The nurse is performing a follow-up teaching session with a client discharged 1 month ago who is taking fluoxetine (Prozac). Which information should be important for the nurse to gather regarding the adverse effects related to the medication?

Gastrointestinal dysfunctions

A client taking buspirone (BuSpar) for 1 month returns to the clinic for a follow-up visit. Which should indicate medication effectiveness?

No rapid heartbeats or anxiety

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 should plan for which appropriate nursing intervention?

Offer to take the client to an examination room until he or she can be treated.

The nurse is assisting in planning care for a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention should the nurse include in the plan of care?

One-to-one suicide precautions

The nurse reviews the activity schedule for the day and determines that the best supervised activity that the manic client could participate in is which?

Ping-Pong

The 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?

Sit beside the client in silence and verbalize occasional open-ended questions.

The nurse assists in planning care for a client scheduled to be discharged from a mental health clinic. The nurse understands that the client's unresolved feelings related to loss may resurface during which phase of the therapeutic nurse-client relationship?

Termination phase

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the data obtained, the nurse should identify which as a priority concern?

The client's report of self-destructive thoughts

The 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 should determine that this type of crisis could be caused by which?

The death of a loved one

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 should suggest which?

The mother should restrict the amount of chocolate and caffeine products in the home.

A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said 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 which?

Weight loss

The 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 should the nurse specifically review to monitor for an adverse effect associated with the use of this medication?

White blood cell count

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids?

Yawning, irritability, diaphoresis, cramps, and diarrhea