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11. A client experiencing alcohol withdrawal is prescribed lorazepam (Ativan) 0.5 mg qid. The physician has ordered a CIWA to be completed every 4 hours. Additional prn lorazepam is based on the following scale: CIWA score of 7 to 12: administer 0.5 mg of lorazepam. CIWA score of >12: administer 1 mg of lorazepam. The client's CIWA score at 0400 was 6, at 0800 was 14, at 1200 was 8, at 1600 was 10, at 2000 was 14, and at 2400 was 6. How many milligrams of lorazepam did the client receive in 1 day? ______ mg.

0.5 mg × 4 = 2 mg (standing dose) 3 mg + 2 mg = 5 mg/day

23. A client in treatment for alcohol use disorder enters the ED complaining of head and neck pain, dizziness, sweating, and confusion. BP 100/60 mm Hg, pulse 130, and respirations 26. Which question should the nurse ask to assess this situation further? 1. "Are you currently on any medications for the treatment of alcohol use disorder?" 2. "How long have you been abstinent from using alcohol?" 3. "Are you currently using any illegal street drugs?" 4. "Have you had any diarrhea or vomiting?"

1. "Are you currently on any medications for the treatment of alcohol use disorder?"

A client diagnosed with antisocial personality disorder demands, at midnight, to speak to the ethics committee about the involuntary commitment process. Which nursing statement is appropriate? 1. "I realize you're upset; however, this is not the appropriate time to explore your concerns." 2. "Let me give you a sleeping pill to help put your mind at ease." 3. "It's midnight, and you are disturbing the other clients." 4. "I will document your concerns in your chart for the morning shift to discuss with the ethics committee."

1. "I realize you're upset; however, this is not the appropriate time to explore your concerns."

6. Which of the following are reasons for the success of 12-step programs such as Alcoholics Anonymous (AA)? Select all that apply. 1. 12-step programs break down denial in an atmosphere of support. 2. 12-step programs give clients a sense of community. 3. 12-step programs help clients recognize the power they have over their addiction. 4. 12-step programs provide clients with experts in the field of addiction. 5. 12-step programs provide sponsors who acclimate clients back into social settings.

1. 12-step programs break down denial in an atmosphere of support. 2. 12-step programs give clients a sense of community.

12. Which of the following are effective ways to identify a substance-impaired nurse? Select all that apply. 1. A nurse who frequently administers medications to other nurses' clients. 2. High absenteeism if the substance source is outside of the work area. 3. Denial of substance abuse problems. 4. A high incidence of incorrect narcotic counts. 5. Poor concentration and difficulty in meeting deadlines.

1. A nurse who frequently administers medications to other nurses' clients. 2. High absenteeism if the substance source is outside of the work area. 3. Denial of substance abuse problems. 4. A high incidence of incorrect narcotic counts. 5. Poor concentration and difficulty in meeting deadlines

A client diagnosed with a personality disorder states, "You are the very best nurse on the unit and not at all like that mean nurse who never lets us stay up later than 9 p.m." This statement would be associated with which personality disorder? 1. Borderline personality disorder. 2. Schizoid personality disorder. 3. Dependent personality disorder. 4. Paranoid personality disorder.

1. Borderline personality disorder.

A client diagnosed with antisocial personality disorder is caught smuggling cigarettes into the nonsmoking clinical area. Which initial nursing intervention is appropriate? 1. Confront the client about the behavior. 2. Tell the client's primary nurse about the situation. 3. Remind all clients of the no smoking policy in the community meeting. 4. Teach alternative coping mechanisms to assist with anxiety.

1. Confront the client about the behavior.

Although there are differences among the three personality disorder clusters, there also are some traits common to all individuals diagnosed with personality disorders. Which of the following are common traits? Select all that apply. 1. Failure to accept the consequences of their own behavior. 2. Self-injurious behaviors. 3. Reluctance in taking personal risks. 4. Cope by altering environment instead. 5. Lack of insight.

1. Failure to accept the consequences of their own behavior. 4. Cope by altering environment instead. 5. Lack of insight.

Which of the following diagnostic criteria describe the characteristics of avoidant personality disorder? Select all that apply. 1. Fearing shame and/or ridicule, does not form intimate relationships. 2. Has difficulty making everyday decisions without reassurance from others. 3. Is unwilling to be involved with people unless certain of being liked. 4. Shows perfectionism that interferes with task completion. 5. Views self as socially inept, unappealing, and inferior.

1. Fearing shame and/or ridicule, does not form intimate relationships. 3. Is unwilling to be involved with people unless certain of being liked. 5. Views self as socially inept, unappealing, and inferior.

5. Which intervention takes priority when dealing with a client experiencing Wernicke-Korsakoff syndrome? 1. Monitor parenteral vitamin B1. 2. Increase fluid intake. 3. Provide prenatal vitamins. 4. Encourage foods high in vitamin C.

1. Monitor parenteral vitamin B1.

1. A newly admitted client with a long history of alcohol use disorder complains of burning and tingling sensations of the feet. The nurse would recognize these symptoms as indicative of which condition? 1. Peripheral neuropathy. 2. Alcoholic myopathy. 3. Wernicke's encephalopathy. 4. Korsakoff's psychosis.

1. Peripheral neuropathy

A client diagnosed with borderline personality disorder superficially cut both wrists, is disruptive in group, and is "splitting" staff. Which nursing diagnosis would take priority? 1. Risk for self-mutilation R/T need for attention. 2. Ineffective coping R/T inability to deal directly with feelings. 3. Anxiety R/T fear of abandonment AEB "splitting" staff. 4. Risk for suicide R/T past suicide attempt.

1. Risk for self-mutilation R/T need for attention.

A nurse encourages an angry client to attend group therapy. Knowing that the client has been diagnosed with a cluster B personality disorder, which client response might the nurse expect? 1. Sarcastically states, "That group is only for crazy people with problems." 2. Scornfully states, "No, can't you see that I'm having a séance with my mom?" 3. Suspiciously states, "No, that room has been bugged." 4. Hesitantly states, "OK, but only if I can sit next to you."

1. Sarcastically states, "That group is only for crazy people with problems."

A 15 year-old client living in a residential facility has a nursing diagnosis of ineffective coping R/T abuse AEB defiant responses to adult rules. Which of the following interventions would address this nursing diagnosis appropriately? Select all that apply. 1. Set limits on manipulative behavior. 2. Refuse to engage in controversial and argumentative encounters. 3. Obtain an order for tranquilizing medications. 4. Encourage the discussion of angry feelings. 5. Remove all dangerous objects from the client's environment.

1. Set limits on manipulative behavior. 2. Refuse to engage in controversial and argumentative encounters. 4. Encourage the discussion of angry feelings.

16. Using the principles of biological theory, what contributing factor puts a client at risk for the diagnosis of alcohol use disorder? 1. The client is a child of a parent diagnosed with alcohol use disorder. 2. The client is fixated in the oral stage of psychosocial development. 3. The client is highly self-critical and has unconscious anxiety. 4. The client is unable to relax or defer gratification.

1. The client is a child of a parent diagnosed with alcohol use disorder

Which behavior would the nurse expect to observe if a client is diagnosed with paranoid personality disorder? 1. The client sits alone at lunch and states, "Everyone wants to hurt me." 2. The client is irresponsible and exploits other peers in the milieu for cigarettes. 3. The client is shy and refuses to talk to others because of poor self-esteem. 4. The client sits with peers and allows others to make decisions for the entire group.

1. The client sits alone at lunch and states, "Everyone wants to hurt me."

15. What substance stimulates the central nervous system? 1. Vodka. 2. "Crack." 3. Lorazepam (Ativan). 4. Triazolam (Halcion).

2. "Crack."

10. The nurse is planning a teaching session for a client who has recently been prescribed disulfiram (Antabuse) as deterrent therapy for alcohol use disorder. What statement indicates that the client has accurate knowledge of this subject matter? 1. "Over-the-counter cough and cold medication should not affect me while I am taking the Antabuse." 2. "I'll have to stop using my alcohol-based aftershave while I am taking the Antabuse." 3. "Antabuse should decrease my cravings for alcohol and make my recovery process easier." 4. "Antabuse is used as a substitute for alcohol to help me avoid alcohol withdrawal symptoms."

2. "I'll have to stop using my alcohol-based aftershave while I am taking the Antabuse."

A client has been diagnosed with a cluster A personality disorder. Which of the following client statements would reflect cluster A characteristics? Select all that apply. 1. "I'm the best chef on the East Coast." 2. "My dinner has been poisoned." 3. "I have to wash my hands 10 times before eating." 4. "I just can't eat when I'm alone." 5. "When my mom died, her spirit entered my cat."

2. "My dinner has been poisoned." 5. "When my mom died, her spirit entered my cat."

17. Which individual would have the lowest potential for being diagnosed with alcohol use disorder? 1. A 32 year-old male Finn. 2. A 20 year-old Asian woman. 3. A 60 year-old Irishman. 4. An 18 year-old Native American.

2. A 20 year-old Asian woman.

22. Three days after surgery to correct a perforated bowel, a client begins to display signs and symptoms of tremors, increased blood pressure, and diaphoresis. What should the nurse suspect? 1. Concealed hemorrhage. 2. Alcohol or other central nervous system depressants induced withdrawal. 3. Malignant hyperpyrexia. 4. Neuroleptic malignant syndrome.

2. Alcohol or other central nervous system depressants induced withdrawal.

8. Which drug would a nurse recognize as appropriate in assisting a client with recovery from long-standing heroin use disorder? 1. Acamprosate calcium (Campral). 2. Buprenorphine/naloxone (Suboxone). 3. Disulfiram (Antabuse). 4. Haloperidol (Haldol).

2. Buprenorphine/naloxone (Suboxone).

14. A client on the substance use disorder unit states, "I used to be able to get a 'buzz on' with a few beers. Now it takes a six-pack." How should the nurse, in the role of teacher, address this remark? 1. By assessing the client's readiness for learning and reviewing the criteria for alcohol induced withdrawal. 2. By explaining the effects of tolerance and telling the client that this is a sign of alcohol use disorder. 3. By presenting the concept of minimization and how this affects a realistic view of the problems precipitated by alcohol use disorder. 4. By confronting the client with the client's use of the defense mechanism of rationalization.

2. By explaining the effects of tolerance and telling the client that this is a sign of alcohol use disorder.

2. Using interpersonal theory, which statement is true regarding development of paranoid personality disorder? 1. Studies have revealed a higher incidence of paranoid personality disorder among relatives of clients with schizophrenia. 2. Clients diagnosed with paranoid personality disorder frequently have been family scapegoats and subjected to parental antagonism and harassment. 3. There is an alteration in the ego development so that the ego is unable to balance the id and superego. 4. During the anal stage of development, the client diagnosed with paranoid personality disorder has problems with control within his or her environment.

2. Clients diagnosed with paranoid personality disorder frequently have been family scapegoats and subjected to parental antagonism and harassment.

Which of the following diagnostic criteria describe the characteristics of borderline personality disorder? Select all that apply. 1. Arrogant, haughty behaviors or attitudes. 2. Frantic efforts to avoid real or imagined abandonment. 3. Recurrent suicidal and self-mutilating behaviors. 4. Unrealistic preoccupation with fears of being left to take care of self. 5. Chronic feelings of emptiness.

2. Frantic efforts to avoid real or imagined abandonment. 3. Recurrent suicidal and self-mutilating behaviors. 5. Chronic feelings of emptiness.

. A client exhibiting passive-aggressive personality traits continuously complains to the marriage counselor about a nagging husband who criticizes her indecisiveness. Which nursing diagnosis reflects this client's problem? 1. Social isolation R/T decreased self-esteem. 2. Impaired social interaction R/T inability to express feelings openly. 3. Powerlessness R/T spousal abuse. 4. Self-esteem disturbance R/T unrealistic expectations of husband.

2. Impaired social interaction R/T inability to express feelings openly.

7. A client with a long history of alcohol use disorder is showing signs of cognitive deficits. What drug would the nurse recognize as appropriate in assisting with this client's alcohol recovery? 1. Disulfiram (Antabuse). 2. Naltrexone (ReVia). 3. Lorazepam (Ativan). 4. Methadone (Dolophine).

2. Naltrexone (ReVia).

After being treated in the ED for self-inflicted lacerations to wrists and arms, a client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. Which nursing intervention takes priority? 1. Administer tranquilizing drugs. 2. Observe client frequently. 3. Encourage client to verbalize hostile feelings. 4. Explore alternative ways of handling frustration.

2. Observe client frequently.

A client diagnosed with paranoid personality disorder needs information regarding medications. Which nursing intervention would best assist this client in understanding prescribed medications? 1. Ask the client to join the medication education group. 2. Provide one-on-one teaching in the client's room. 3. During rounds, have the physician ask if the client has any questions. 4. Let the client read the medication information handout.

2. Provide one-on-one teaching in the client's room

A client diagnosed with a personality disorder insists that a grandmother, through reincarnation, has come back to life as a pet kitten. The thought process described is reflective of which personality disorder? 1. Obsessive-compulsive personality disorder. 2. Schizotypal personality disorder. 3. Borderline personality disorder. 4. Schizoid personality disorder.

2. Schizotypal personality disorder.

3. A client diagnosed with borderline personality disorder coyly requests diazepam (Valium). When the physician refuses, the client becomes angry and demands to see another physician. What defense mechanism is the client using? 1. Undoing. 2. Splitting. 3. Altruism. 4. Reaction formation.

2. Splitting.

3. A client has been diagnosed with Wernicke-Korsakoff syndrome. Which describes this client's use of confabulation? 1. The client has difficulty keeping thoughts focused and on the topic. 2. The client clearly discussed a field trip, when in reality no field trip occurred. 3. The client jumps from one topic to another. 4. The client lies about anxiety level rating to receive more anxiolytics.

2. The client clearly discussed a field trip, when in reality no field trip occurred.

18. Which of the following sociocultural factors increase a client's risk for the diagnosis of alcohol use disorder? Select all that apply. 1. The client's twin sister has been diagnosed with alcohol use disorder. 2. The client was raised in a home where alcohol use was the norm. 3. The client is from a family that culturally accepts the use of alcohol. 4. The client experiences pleasure when using alcohol and subsequently repeats the use. 5. The client is influenced by morphine-like substances produced during alcohol use.

2. The client was raised in a home where alcohol use was the norm. 3 The client is from a family that culturally accepts the use of alcohol. 4. The client experiences pleasure when using alcohol and subsequently repeats the use.

20. A client who is exhibiting symptoms of alcohol induced withdrawal is admitted to the substance abuse unit for detox. One of the nursing diagnoses for this client is ineffective health maintenance. Which is a correctly written long-term outcome for this nursing diagnosis? 1. The client will agree to attend nutritional counseling sessions. 2. The client will exhibit reduced medical complications related to alcohol use disorder within 6 months. 3. The client will identify at least three effects of alcohol on the body by day 2 of hospitalization. 4. The client will remain free from injury while withdrawing from alcohol.

2. The client will exhibit reduced medical complications related to alcohol use disorder within 6 months.

A suicidal client is diagnosed with borderline personality disorder. Which correctly written short-term outcome is most beneficial for the client? 1. The client will be free from self-injurious behavior. 2. The client will express feelings without inflicting self-injury by discharge. 3. The client will socialize with peers in the milieu by day 3. 4. The client will acknowledge his or her role in altered interpersonal relationships.

2. The client will express feelings without inflicting self-injury by discharge.

13. A client diagnosed with alcohol use disorder states that his wife complains about his drinking but stocks his bar with gin. The nurse suspects codependency. Which of the following characteristics would the nurse expect the wife to exhibit? Select all that apply. 1. The wife has a long history of egocentric tendencies. 2. The wife is a "people pleaser" and would do almost anything to gain approval. 3. The wife does not feel responsible for making her husband happy. 4. The wife has an accurate understanding regarding her own identity. 5. The wife experiences a profound sense of powerlessness.

2. The wife is a "people pleaser" and would do almost anything to gain approval. 5. The wife experiences a profound sense of powerlessness.

21. The nurse has given a client information on alcohol use disorder recovery. Which client statement indicates that learning has occurred? 1. "Once I have detoxed, my recovery is complete." 2. "I understand that the goal of recovery is to decrease my drinking." 3. "I realize that recovery is a lifelong process that comes about in steps." 4. "Al-Anon can assist me in my recovery process."

3. "I realize that recovery is a lifelong process that comes about in steps."

A nursing instructor is teaching about personality disorder characteristics. Which student statement indicates that learning has occurred? 1. "Clients diagnosed with personality disorders need frequent hospitalizations." 2. "Clients perceive their behaviors as uncomfortable and disorganized." 3. "Personality disorders cannot be cured or controlled successfully with medication." 4. "Practitioners have a good understanding about the etiology of personality disorders."

3. "Personality disorders cannot be cured or controlled successfully with medication."

23. Which client situation requires the nurse to prioritize the implementation of limit setting? 1. A client making sexual advances toward a staff member. 2. A client telling staff that another staff member allows food in the bedrooms. 3. A client verbally provoking another client who is paranoid. 4. A client refusing medications to receive secondary gains.

3. A client verbally provoking another client who is paranoid.

A client diagnosed with antisocial personality disorder states, "My kids are so busy at home and school, they don't miss me or even know I'm gone." Which nursing diagnosis applies to this client? 1. Risk for injury. 2. Risk for violence: self-directed. 3. Ineffective denial. 4. Powerlessness.

3. Ineffective denial.

9. A client receives lorazepam (Ativan) because of a high Clinical Institute Withdrawal Assessment (CIWA) score. What is the rationale for this pharmacological intervention? 1. Lorazepam is a medication that decreases cravings in clients who are experiencing alcohol induced withdrawal. 2. Lorazepam is a deterrent therapy that helps to motivate clients to maintain alcohol abstinence. 3. Lorazepam is a substitution therapy to decrease the intensity of withdrawal symptoms. 4. Lorazepam is a central nervous system stimulant that decreases the CIWA score.

3. Lorazepam is a substitution therapy to decrease the intensity of withdrawal symptoms.

2. A client with a long history of alcohol use disorder recently has been diagnosed with Wernicke-Korsakoff syndrome. Which of the following symptoms should the nurse expect to assess? Select all that apply. 1. A sudden onset of muscle pain with elevations of creatine phosphokinase. 2. Signs and symptoms of congestive heart failure. 3. Loss of short-term and long-term memory and the use of confabulation. 4. Inflammation of the stomach and gastroesophageal reflux disorder. 5. Lab values that document severe thiamine deficiency.

3. Loss of short-term and long-term memory and the use of confabulation. 5. Lab values that document severe thiamine deficiency.

A client tells the nurse, "When I was a waiter I used to spit in the dinners of annoying customers." This statement would be associated with which personality trait? 1. Paranoid personality trait. 2. Schizoid personality trait. 3. Passive-aggressive personality trait. 4. Antisocial personality trait.

3. Passive-aggressive personality trait.

4. Which is the priority diagnosis for a client experiencing alcohol induced withdrawal? 1. Ineffective health maintenance. 2. Ineffective coping. 3. Risk for injury. 4. Dysfunctional family processes: alcohol use disorder.

3. Risk for injury.

A client diagnosed with a dependent personality disorder has a nursing diagnosis of social isolation R/T parental abandonment AEB fear of involvement with individuals not in the immediate family. Which nursing intervention would be appropriate? 1. Address inappropriate interactions during group therapy. 2. Recognize when client is playing one staff member against another. 3. Role-model positive relationships. 4. Encourage client to discuss conflicts evident within the family system.

3. Role-model positive relationships.

A client diagnosed with an avoidant personality disorder has the nursing diagnosis of social isolation R/T severe malformation of the spine AEB "I can't be around people, looking like this." Which correctly written short-term outcome is appropriate for this client's problem? 1. The client will see self as straight and tall by the time of discharge. 2. The client will see self as valuable after attending assertiveness training courses. 3. The client will be able to participate in one therapy group by end of shift. 4. The client will join in a charade game to decrease social isolation.

3. The client will be able to participate in one therapy group by end of shift.

A client newly admitted to an in-patient psychiatric unit is diagnosed with schizotypal personality disorder. The client states, "I envision my future death by fire." Which is the most appropriate nursing response? 1. "I don't know what you mean by envisioning your future death." 2. "Your future death? Can you please tell me more about that?" 3. "I was wondering if you want to come to group to talk about that." 4. "I can see your thoughts are bothersome. How can I help?"

4. "I can see your thoughts are bothersome. How can I help?"

A nursing student is learning about narcissistic personality disorder. Which of the following student statements indicate that learning has occurred? Select all that apply. 1. "These clients have peculiarities of ideation." 2. "These clients require constant approval and affirmation." 3. "These clients are impulsive and self-destructive." 4. "These clients express a grandiose sense of self-importance." 5. "These clients have a deep need for admiration."

4. "These clients express a grandiose sense of self-importance."

When assessing a client diagnosed with histrionic personality disorder, the nurse might identify which characteristic behavior? 1. Odd beliefs and magical thinking. 2. Grandiose sense of self-importance. 3. Preoccupation with orderliness and perfection. 4. Attention-seeking flamboyance.

4. Attention-seeking flamboyance.

Personality disorders are grouped in clusters according to their behavioral characteristics. In which cluster are the disorders correctly matched with their behavioral characteristics? 1. Cluster C: antisocial, borderline, histrionic, narcissistic disorders; anxious or fearful characteristic behaviors. 2. Cluster A: avoidant, dependent, obsessive-compulsive disorders; odd or eccentric characteristic behaviors. 3. Cluster A: antisocial, borderline, histrionic, narcissistic disorders; dramatic, emotional, or erratic characteristic behaviors. 4. Cluster C: avoidant, dependent, obsessive-compulsive disorders; anxious or fearful characteristic behaviors.

4. Cluster C: avoidant, dependent, obsessive-compulsive disorders; anxious or fearful characteristic behaviors.

Which diagnostic criterion describes a characteristic of schizotypal personality disorder? 1. Neither desires nor enjoys close relationships, including being part of a family. 2. Is preoccupied with unjustified doubts about the loyalty of friends and associates. 3. Considers relationships to be more intimate than they actually are. 4. Exhibits behavior or appearance that is odd, eccentric, or peculiar.

4. Exhibits behavior or appearance that is odd, eccentric, or peculiar.

A client diagnosed with a borderline personality disorder is given a nursing diagnosis of disturbed personal identity R/T unmet dependency needs AEB the inability to be alone. Which nursing intervention would be appropriate? 1. Ask the client directly, "Have you thought about killing yourself?" 2. Maintain a low level of stimuli in the client's environment. 3. Frequently orient the client to reality and surroundings. 4. Help the client identify values and beliefs.

4. Help the client identify values and beliefs.

A male client diagnosed with a personality disorder boasts to the nurse that he has to fight off female attention and is the highest paid in his company. These statements are reflective of which personality disorder? 1. Obsessive-compulsive personality disorder. 2. Avoidant personality disorder. 3. Schizotypal personality disorder. 4. Narcissistic personality disorder.

4. Narcissistic personality disorder.

A nurse is discharging a client diagnosed with narcissistic personality disorder. Which employment opportunity is most likely to be recommended by the treatment team? 1. Home construction. 2. Air traffic controller. 3. Night watchman at the zoo. 4. Prison warden.

4. Prison warden.

19. Which is the priority nursing diagnosis for a client experiencing alcohol induced intoxication? 1. Pain. 2. Ineffective denial. 3. Ineffective coping. 4. Risk for aspiration.

4. Risk for aspiration.

A client diagnosed with schizoid personality disorder chooses solitary activities, lacks close friends, and appears indifferent to criticism. Which nursing diagnosis would be appropriate for this client's problem? 1. Anxiety R/T poor self-esteem AEB lack of close friends. 2. Ineffective coping R/T inability to communicate AEB indifference to criticism. 3. Altered sensory perception R/T threat to self-concept AEB magical thinking. 4. Social isolation R/T discomfort with human interaction AEB avoiding others.

4. Social isolation R/T discomfort with human interaction AEB avoiding others.

When assessing a client exhibiting passive-aggressive personality traits, which characteristic behavior might the nurse identify? 1. The client exhibits behaviors that attempt to "split" the staff. 2. The client shows reckless disregard for the safety of self or others. 3. The client has unjustified doubts about the trustworthiness of friends. 4. The client seeks subtle retribution when feeling others have wronged him or her.

4. The client seeks subtle retribution when feeling others have wronged him or her.

1. Which predisposing factor would be implicated in the etiology of paranoid personality disorder? 1. The individual may have been subjected to parental demands, criticism, and perfectionistic expectations. 2. The individual may have been subjected to parental indifference, impassivity, or formality. 3. The individual may have been subjected to parental bleak and unfeeling coldness. 4. The individual may have been subjected to parental antagonism and harassment.

4. The individual may have been subjected to parental antagonism and harassment.

A client diagnosed with an obsessive-compulsive personality disorder has a nursing diagnosis of anxiety R/T interference with hand washing AEB "I'll go crazy if you don't let me do that." Which correctly written short-term outcome is appropriate for this client? 1. During a 3-hour period after admission to the unit, the client will refrain from hand washing. 2. The client will wash hands only at appropriate bathroom and meal intervals. 3. The client will refrain from hand washing throughout the night. 4. Within 72 hours of admission, the client will notify staff when signs and symptoms of anxiety escalate.

4. Within 72 hours of admission, the client will notify staff when signs and symptoms of anxiety escalate.

Chapter 24

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