Evolve Psych Foudations

A client who appears dejected, barely responds to questions, and walks very slowly about the mental health unit tells the nurse in a barely audible voice that life is no longer worth living. What is the most therapeutic response to this statement by the nurse?

"Have you been thinking about suicide?"

A client is agitated and threatening staff and other clients with physical harm. The nurse prepares to administer the prescribed PRN haloperidol (Haldol) after other means to deescalate the behavior have failed. The prescription calls for the administration of 5 mg of haloperidol intramuscularly PRN for severely agitated/aggressive behavior. The haloperidol is available in a vial labeled "2 mg/mL." How many milliliters of solution should the nurse administer? Record your answer rounding to one decimal place. __________ mL

2.5

A parent of four is remanded to the psychiatric unit by the court for observation. The client was arrested and charged with abusing a 2-year-old son, who is in the pediatric intensive care unit in critical condition. The nurse approaches the client for the first time. How should the nurse anticipate that the client will likely respond? (Select all that apply.)

By denying beating the son By avoiding talking about the situation Emotional response is inconsistent with degree of injury

When planning care for an older client, the nurse remembers that aging has little effect on a client's:

Capacity to handle life's stresses

A recently married 22-year-old woman is brought to the trauma center by the police. She has been robbed, beaten, and sexually assaulted. The client, although anxious and tearful, appears to be in control. The health care provider prescribes alprazolam (Xanax) 0.25 mg for agitation. The nurse should administer this medication when the:

Client requests something to calm her

A male college student who is smaller than average and unable to participate in sports becomes the life of the party and a stylish dresser. What defense mechanism does the nurse determine that the client is using?

Compensation

An Asian client arrives at the mental health clinic with symptoms of anxiety and panic. While speaking with the client, the nurse notes that the client makes very little eye contact. What does this behavior suggest?

Cultural variation

A nonviolent client on the psychiatric unit suddenly refuses to take the prescribed antipsychotic medication. What should the nurse do?

Honor the client's decision and document the behavior and all interventions

A nurse in the mental health clinic concludes that a client is using confabulation when:

Imagination is used to fill in memory gaps

Which nursing intervention involves providing, structuring, and maintaining a safe and therapeutic environment in collaboration with patients, families, and other health care providers?

Milieu therapy

A client who is taking lithium arrives at the mental health center for a routine visit. The client has slurred speech, has an ataxic gait, and complains of nausea. The nurse knows that these signs and symptoms are:

Probably associated with a toxic level of lithium

Doxepin (Sinequan) is prescribed for a 74-year-old man for treatment of a depressive episode that has not responded to several other medications. The nurse in the outpatient clinic reviews with the client the side effects of doxepin. The identification of which side effects by the client as needing to be reported to the health care provider allows the nurse to conclude that the teaching has been effective? (Select all that apply.)

Retention of urine Thoughts of suicide

Three days after a stressful incident a client can no longer remember why it was stressful. The nurse, in relating to this client, can be most therapeutic by identifying that the inability to recall the situation is an example of the defense mechanism of:

Repression

What is most important for a nurse to have when working with families who are encountering problems?

Sense of self and empathy for others

After several interactions with a client, the nurse at the mental health clinic identifies a pattern of withdrawal and nonparticipation in situations requiring communication with others. In which area should the nurse expect the client to have difficulty?

Social interaction

Which is the most important information for a nurse to gather from the client in crisis?

The client's perception of the circumstances surrounding the crisis

During a group meeting a client tells everyone, "I'm about to be discharged from the hospital, and I'm afraid." What is the most appropriate response by the nurse facilitator?

"Maybe others in the group have similar feelings that they would share."

On the psychiatric unit a client has been receiving high doses of haloperidol (Haldol) for 2 weeks. The client says, "I just can't sit still, and I feel jittery." Which side effect does the nurse suspect that the client is experiencing?

Akathisia

A client is scheduled for several diagnostic studies. Which behavior best indicates to the nurse that the client has received adequate preparation?

Arrives early and waits quietly to be called for the tests

An 18 year-old woman is brought to the emergency department by her two roommates after being found unconscious in the bathroom. Laboratory tests are ordered. The nurse reviewing the findings notes that the urinalysis is positive for flunitrazepam (Rohypnol). The nurse knows that flunitrazepam is often used:

As a date rape drug

A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how much I love him, but I don't want to upset him." Which is the best response by the nurse?

"Why don't you share your feelings with him while you can?

During a group discussion regarding the unexpected suicide of a young female client who was on a weekend pass, one of the other clients stands up and shouts, "Oh, I know what you're all thinking. You think that I should've known that she was going to kill herself. You think I helped her plan this." What is the most therapeutic response by the group leader?

"You're upset because you think we're blaming you for her death?

A nurse counseling a female client on the inpatient psychiatric unit responds to a statement made by the woman by stating, "I'm confused about exactly what is upsetting you. Would you go over that again, please?" The nurse is using:

Clarifying

On the first day of the month a practitioner prescribes an antipsychotic medication for a client with schizophrenia. The initial dosage is 25 mg once a day, to be titrated in increments of 25 mg every other day to a desired dosage of 175 mg daily. On what day of the month will the client reach the desired daily dose of 175 mg?

Day 13

A nurse is caring for a 20-year-old client. According to Erikson's developmental psychosocial theory, what is expected by 20 years of age?

Having a coherent sense of self and plans for self-actualization

A disturbed client who has been out of touch with reality has been hospitalized for several weeks. One day the nurse notes that the client's hair is dirty and asks whether the client wants to wash it. The client answers, "Yes, and I'd like to shower and change my clothes, too." What can the nurse conclude about the client in relation to this response?

He has some feelings of self-worth.

A woman with five children comes to the emergency department with multiple facial injuries. The client says, "My husband is an alcoholic, and he just beat me up." The nurse concludes that the client appears to be a victim of abuse. What should the nurse do next?

Inquire about her and the children's safety

A client has become increasingly depressed, and the practitioner prescribes an antidepressant. After 20 days of therapy, the client returns to the clinic. The client appears relaxed and smiles at the nurse. The most significant conclusion that the nurse can draw from this behavior is that the client:

Is responding to the antidepressant therapy

A nurse is caring for a client who is angry and agitated. What is the best approach for the nurse to use with this client?

Maintaining a calm, consistent approach with the client

An older female client is concerned about maintaining her independent living status. What initial intervention strategy is of primary importance?

Reinforcing routines and supporting her usual habits

A nurse is aware that a co-worker's mother died 16 months ago. The co-worker cries every time someone says the word "mother" and when the mother's name is mentioned. What does the nurse conclude about this behavior?

The co-worker may need help with grieving