Exam 2 - Mental Health PP Questions, Quiz #3, Quiz #4, 26, 27, 28, 31, 24, 21, 23, 15, 34

4. Carol has sought treatment for an adjustment disorder after divorcing her husband of 30 years. The nurse assesses that Carol is experiencing complicated grieving. Which of the following would be an appropriate intervention to address Carol's symptoms? 1) Explore with Carol the stages of normal grieving. 2) Tell Carol that expressing anger will only keep her fixated at that stage of grieving. 3) Encourage Carol that these symptoms usually go away on their own. 4) All of the above.

1) Explore with Carol the stages of normal grieving. It is appropriate to encourage exploration and identification of which stage of grieving Carol is currently experiencing.

9. Jennifer is working with the nurse on her care plan related to post trauma syndrome. Jennifer repeatedly asks the nurse why she is writing down everything and who will be seeing this information. Which of these interpretations by the nurse reflects an understanding of the post trauma patient? 1) Post trauma patients may be suspicious of others in their environment. 2) Post trauma patients need a lot of redirection. 3) Female post trauma patients are often very confused about details. 4) Post trauma patients are always confrontational and challenging with health care professionals.

1) Post trauma patients may be suspicious of others in their environment. An understanding that post trauma patients may be suspicious of others in the environment will assist the nurse in responding to the patient in a manner that promotes trust between them.

25. Which of the following client statements would appear in a nursing assessment of a person exhibiting the appropriate expression of anger? 1. "I'm sick and tired of my family asking me how I am doing. How do they think I'm doing?" 2. "I wonder how he would feel if I got drunk then drove head-on into his wife's car?" 3. "I smashed a hole in the wall and broke a table. It's not like I hit my wife or anything." 4. "I don't really hit my kids. I just tell them I'm going to beat their backside if they don't clean their room."

1. This is correct. A patient who is appropriately expressing anger through hypersensitivity, being easily offended, or having a defensive response to criticism could make this statement

12. When least-restrictive methods fail for an angry, aggressive client, a physician orders restraints at 3 a.m. Per Joint Commission standards, at what time and by whom does the nurse expect an in-person client evaluation? 1. No later than 4 a.m., by a physician or an LIP 2. No later than 5 a.m., by a physician or an LIP 3. No later than 4 a.m., by a psychiatrist or the clinical nurse specialist 4. No later than 5 a.m., by the psychiatrist or a clinical nurse specialist

1. This is correct. A physician or LIP must perform an in-person evaluation of the client no later than 4 a.m. Per Joint Commission standards, an in-person evaluation by a physician or LIP must be conducted within 1 hour of the initiation of restraints.

26. A nurse notices a client clenching fists periodically and pacing the hallway. Which nursing interventions should the nurse implement? Select all that apply. 1. Acknowledge the client's behavior. 2. Initiate forced-medication protocol. 3. Assist the client to a quiet area. 4. Initiate confinement measures. 5. Speak with a soft and calming voice.

1. This is correct. Acknowledging the client's behavior communicates empathy and validates the client's feelings. 3. This is correct. Reducing stimulation in the environment de-escalates anger. Acknowledging the client's behavior communicates empathy and validates the client's feelings. 5. This is correct. Remaining calm reduces agitation. Anger expressed by the nurse will most likely incite increased anger in the client.

27. Which of the following statements about anger are true? Select all that apply. 1. Anger is not a primary emotion. Townsend PMHN, 10e Chapter 15 - ETB 2. Anger is a physiological arousal. 3. Anger reflects a desire for dominance and control. 4. Anger, in general, may range from a self-protective response to a violent act. 5. Anger, when not expressed appropriately, can result in depression and low selfesteem.

1. This is correct. Anger is not a primary emotion, but it is typically experienced as an almost-automatic inner response to hurt, frustration, or fear 2. This is correct. Anger is a physiological arousal. It instills feelings of power and generates preparedness 5. This is correct. When turned inward on oneself, anger can result in depression and low self-esteem.

30. A person who demonstrates the ability to exert _________ __________ over feelings of anger would demonstrate a successful nursing outcome in the care of the client needing assistance with anger management. 1. Internal control 2. Problem-solving 3. Aggression diffusion 4. Constructive tension

1. This is correct. Demonstrating the ability to exert internal control over feelings of anger, taking responsibility for one's own feelings of anger, recognizing anger, seeking support to talk about feelings, and using the tension generated by the anger in a constructive manner are all examples of successful outcomes

15. A client begins to smash furniture, cannot be "talked down," and refuses medications. Which is the priority nursing intervention? 1. Call a violence code. 2. Ask the ward clerk to put in a call to the physician. 3. Place the client in seclusion. 4. Place the client in four-point restraints.

1. This is correct. Patient and staff safety are the priorities. Have several trained staff respond to a violence code to prevent injury to the client and staff.

22. A client arrives at the primary care physician with complaints of increased symptoms of colitis. During the intake interview, the patient mentions having two migraines in the past 3 weeks and asks for a new medication, stating, "It doesn't seem like the current medication is working as well as I expected." In reviewing the client's medical record, it is noted that the client was prescribed medication for depression and a referral to a marriage counselor at her last visit 2 months ago. Which of the following might the nurse suspect? 1. Maladaptive expression of anger 2. Hypersensitivity to migraine medication 3. Exhibiting signs of domestic abuse 4. Operant conditioning

1. This is correct. The patient presents with a diagnosis of colitis and depression and has recently received medications for depression and migraines. These symptoms are manifestations of ineffective expression of anger. The symptoms will not go away if the cause (ineffective anger expression) is not resolved.

3. Which client statement demonstrates improvement in anger and aggression management? 1. "I realize I have a problem expressing my anger appropriately." 2. "I know I can't use physical force anymore, but I can verbally intimidate others." 3. "It's bad to feel as angry as I feel. I'm working on eliminating this poisonous emotion entirely." 4. "Because my wife seems to be the one to set me off, I've decided to remain separated from her."

1. This is correct. This statement indicates that the client is taking responsibility for his or her anger.

6. During a psychiatric nursing assessment, Sally reports to the nurse that she was sexually assaulted 6 months ago and since then has had trouble concentrating at work. Her employer tells her he is sensitive to the amount of stress she is under, since she also recently went through a divorce, but that she needs to seek help for her anxiety and depression to avoid further consequences at work. Which of these data support the diagnosis of PTSD according to DSM-5 criteria? Select all that apply. 1) She directly experienced a traumatic event. 2) She is a single female. 3) She has had difficulty concentrating at work. 4) Her anxiety and depression are interfering with job functioning. 5) Her symptoms have been present for more than 6 months.

1: Exposure to actual or threatened death, serious injury, or sexual violence is defined as trauma that meets diagnostic criteria for PTSD according to the DSM-5. 3: Problems with concentration that are associated with traumatic events are identified in DSM-5 as part of the diagnostic criteria for PTSD. 4: Clinically significant impairment in occupational function is a diagnostic criterion for PTSD, according to the DSM-5. 5: Symptoms present for more than 1 month warrant a diagnosis of PTSD.

7. An adult male has sought counseling at a community mental health center for PTSD. He reports during assessment that he witnessed the murder of a close friend last year in a random, drive-by shooting in his neighborhood. Since this loss he has had recurrent nightmares, explosive episodes, and frequently incapacitating anxiety. Which of the following nursing diagnoses would be appropriate, based on this assessment data? Select all that apply. 1) Post Trauma Syndrome R/T distressing events, as evidenced by recurrent nightmares. 2) Complicated grieving R/T loss of a friend in the traumatic event, as evidenced by explosive outbursts and reports of incapacitating anxiety. 3) Isolation R/T unresolved anxiety, as evidenced by complaints of incapacitating anxiety. 4) Risk for suicide R/T survivor guilt.

1: Recurrent nightmares connected to the experience of a traumatic experience indicate that Post Trauma Syndrome is an appropriate nursing diagnosis. 2: The experience of significant psychological and/or physiological distress in response to a loss implies that complicated grieving is an appropriate nursing diagnosis.

5. John has been in counseling for an adjustment disorder related to losing his management position in a health care facility. He tells the counselor he feels ready to terminate counseling. Which of these statements by the patient supports his readiness to terminate counseling? 1) "Counseling isn't going to get me another job, so what's the point?" 2) "I don't feel angry anymore and I've learned how to relax better." 3) "I've decided I'm never going to work again, so I'm applying for disability." 4) "As long as I continue to take antianxiety medication, I'll be okay."

2) "I don't feel angry anymore and I've learned how to relax better." This response demonstrates progression through the grieving process and use of an appropriate coping skill.

12. Beth is being treated for an adjustment disorder following a job demotion 2 months ago. Since the demotion, she has frequently called in sick, complains of incapacitating migraines, and has been disciplined for yelling at her boss. Her husband asks the nurse why his wife is still having so much trouble functioning, since he knows people who have lost their jobs entirely and have since resolved their concerns. Which of these statements by the nurse accurately reflects understanding of the dynamics of different kinds of stressors in patient recovery? 1) Women have more difficulty managing work-related stressors than men. 2) Ongoing stressors are associated with more maladaptive behaviors than sudden-shock types of stressors. 3) Job demotion is associated with longer-term recovery because it is so uncommon. 4) Carol probably had pre-existing difficulties managing stressors as a child.

2) Ongoing stressors are associated with more maladaptive behaviors than sudden-shock types of stressors. There is evidence that continuous stressors are associated with more maladaptive behaviors than sudden-shock stressors.

2. The family of a patient being treated for PTSD asks the nurse to describe EMDR (eye movement desensitization and reprocessing), since it is being recommended for this patient. Which of the following teaching points are accurate descriptions of this intervention? Select all that apply. 1) EMDR has been shown to be effective in the treatment of all mental illnesses, including schizophrenia. 2) The process involves rapid eye movement while processing painful memories. 3) This process is contraindicated for patients with retinal detachment or glaucoma. 4) This process is thought to relieve anxiety so that the trauma can be processed from a more detached perspective. 5) The biological mechanism that makes EMDR effective is that it releases opioid-like chemicals in the brain.

2) The process involves rapid eye movement while processing painful memories. 3) This process is contraindicated for patients with retinal detachment or glaucoma. 4) This process is thought to relieve anxiety so that the trauma can be processed from a more detached perspective.

29. ___________ ____________ is a personal signal of threat or injustice against the self. The signal elicits coping responses to deal with the distress. 1. Passive-aggressiveness 2. Anger arousal 3. Impulsive behavior 4. Exaggerated control

2. This is correct. Anger arousal is a personal signal of threat or injustice against the self. The signal elicits coping responses to deal with the distress.

2. The nurse is discussing the concept of anger versus aggression with clients during a counseling session. Which of the following statements best differentiates between anger and aggression? 1. "Aggression is a physiological arousal state due to a painful experience, where anger is a learned behavior." 2. "Anger is a normal, healthy emotional response to a negative stimulus, where aggression is an expression of anger." 3. "Aggression is a normal emotional response to a negative stimulus, where anger is an emotional expression of aggression." 4. "There is no difference between anger and aggression; they are essentially the same phenomenon."

2. This is correct. Anger is a normal emotion that is typically experienced as an almostautomatic inner response to negative stimuli such as emotional pain, frustration, or fear. Aggression is a behavioral response of anger intended to inflict pain to or injury to others.

9. Once the nurse initiates restraints for an out-of-control 45-year-old patient, per Joint Commission standards, what must occur within 1 hour? 1. The patient must be let out of restraints. 2. A physician or other LIP must conduct an in-person evaluation. 3. The patient must be bathed and fed. 4. The patient must be included in debriefing.

2. This is correct. Joint Commission standards require that a physician or other LIP conduct an in-person evaluation of the client within 1 hour of the initiation of restraint.

18. The nurse observes a client's escalating anger. The client begins to pace the hall and shouts, "You all better watch out. I'm going to hurt anyone who gets in my way." Which is the priority nursing intervention? 1. Calmly tell the client, "Staff will help you to control your impulse to hurt others." 2. Remove other clients from the area and maintain milieu safety. 3. Gather a show of force by contacting security for assistance. 4. Calmly tell the client, "You will need to be medicated and secluded."

2. This is correct. Maintaining client and nurse safety is always the priority. The nurse's priority action is to remove all clients from the area of conflict, as the situation is emergent.

21. Which nursing approach is likely to be most therapeutic when dealing with a newly admitted, hostile, suspicious client? 1. Place a hand on the client's shoulder and state, "I will help you to your room." 2. Slowly and matter-of-factly state, "I am your nurse and I will show you to your room." 3. Firmly set limits by stating, "If your behavior does not improve, you will be secluded." 4. Smile and state, "I am your nurse. When do you want to go to your room?"

2. This is correct. Remain calm when dealing with an angry client. Anger expressed by the nurse will most likely incite increased anger in the client

10. Physical restraints are sometimes a necessary intervention for clients. This is based on which premise? 1. Clients with poor boundaries do not respond to verbal redirection, and they need firm and consistent limit-setting. 2. Clients with limited internal control over their behavior need external controls to prevent harm to themself and others. 3. Clients with antisocial tendencies need to submit to the staff's authority. 4. Clients with behavioral dysfunction need strict limits and behavioral interventions.

2. This is correct. Restraints are sometimes necessary when clients have limited internal control over their behavior and need external controls (restraints) to prevent harm to themself and others. Restraints are removed as soon as the client has regained control. The least-restrictive interventions are used unless the client is a danger to self or others.

16. On an inpatient psychiatric unit, a restrained 16-year-old client continues to lash out verbally and threatens to abuse staff and kill himself or herself when released. Per Joint Commission standards, when does the nurse expect the physician or LIP to renew the client's restraint order? 1. Within 1 hour of the original restraint order 2. Within 2 hours of the original restraint order 3. Within 3 hours of the original restraint order 4. Within 4 hours of the original restraint order

2. This is correct. The Joint Commission requires a physician or an LIP to reissue a new order for restraints every 2 hours for adolescents.

28. The nurse determines that the goal has been met when the client with anger issues is able to___________________. 1. Take medications on a routine basis. 2. Transfer tension into artwork. 3. Decide what to have for dinner. 4. Speak in front of a large crowd.

2. This is correct. The client is able to transfer tension generated by the anger into constructive activities instead of violent behavior. This is a positive outcome.

7. An adult client assaults another client and is placed in restraints. Which client statement alerts the nurse that further assessment is necessary? 1. "I hate all of you!" 2. "My fingers are tingly." 3. "You wait until I tell my lawyer." 4. "I have a sinus headache."

2. This is correct. The client's statement "My fingers are tingly" indicates that the restraints are too tight and impeding circulation.

1. A student nurse has just entered a psychiatric rotation. The student asks a nursing instructor, "How will we know if someone may get violent?" Which is the most appropriate reply by the nursing instructor? 1. "You can't really say for sure. There are limited indicators of potential violence." 2. "Certain behaviors indicate a potential for violence, such as rigid posture, clenched fists, and raised voice." 3. "Any client can become violent, so be aware of your surroundings at all times." 4. "When a client suddenly becomes quiet, is withdrawn, and maintains a flat affect, this is an indicator of potential violence."

2. This is correct. The most appropriate statement by the instructor is "Certain behaviors indicate a potential for violence. They are labeled as a 'prodromal syndrome' and include rigid posture, clenched fists, and raised voice." Rigid posture, clenched fists, and raised voice are predictors of violent behavior.

13. Which risk factor should a nurse recognize as the most reliable indicator of potential client violence? 1. Diagnosis of schizotypal personality disorder 2. History of assaultive behavior 3. Family history of violence 4. Recent eviction from a homeless shelter

2. This is correct. The most widely recognized risk factor for client violence is a prior history of assault

4. A client is served divorce papers while on the inpatient psychiatric unit. When the nurse tells the client that the unit telephone cannot be used after-hours, the client raises his fists, swears, and spits at the nurse. What would be the priority nursing diagnosis at this time? 1. Ineffective coping related to dysfunctional family system as evidenced by (AEB) aggressive behavior 2. Risk for violence related to dysfunctional family system AEB aggressive behavior 3. Risk for anger related to dysfunctional family system AEB aggressive behavior 4. Ineffective grieving related to dysfunctional family system AEB pending divorce

2. This is correct. This would be a priority nursing diagnosis as the client has displayed aggressive and violent behavior toward the nurse.

14. During the debriefing after a violent episode, the client states that they acted out on their perceived threat from which of the staff behaviors? 1. The staff member administered the client's prn medications when the client showed signs of "prodromal syndrome." 2. The staff member attempted to soothe the client by stroking their arm and shoulder and talking in a firm tone. 3. The staff member called for assistance and asked the ward secretary to contact the client's physician. 4. The nurse separated the client from the others with signs of "prodromal syndrome."

2. This is correct. Touching the client may be perceived as a threat and provoke further violence.

13. A patient admitted to the psychiatric unit, who has been experiencing flashbacks and troubling nightmares, reports to the nurse that he just awoke from a nightmare and is still having chest pain. Which of these nursing interventions is a priority? 1) Encourage the patient to return to bed and try to calm down. 2) Administer prn antianxiety medication as ordered. 3) Assess the patient's cardiovascular status. 4) Encourage the patient to reflect on the troubling dream.

3) Assess the patient's cardiovascular status. This intervention is the most important priority since complaints of chest pain should not be assumed to be solely anxiety symptoms. The patient may be having a heart attack.

8. A patient with PTSD who has been having nightmares is prescribed propranolol to treat PTSD symptoms. He asks the nurse why this medication was ordered since he doesn't have high blood pressure. Which of the following is the most appropriate response by the nurse at this point? 1) Call the doctor and question this order. 2) Discontinue the medication and check the patient's blood pressure. 3) Explain that propranolol has been shown to be effective in reducing nightmares associated with PTSD. 4) Explain that this medication is used to treat hypertension that often accompanies PTSD.

3) Explain that propranolol has been shown to be effective in reducing nightmares associated with PTSD. There is established evidence that propranolol is effective in reducing nightmares associated with PTSD, and this response addresses the immediate client need for information about the medication ordered.

1. Jared returned from active duty in the military and has been diagnosed with PTSD. Which of the following interventions has been strongly advocated for as an effective strategy in this population? 1) Group therapy with patients who have a variety of diagnoses 2) Group therapy with patients who have anger management issues 3) Group therapy with patients who have experienced similar traumas 4) Group therapy with patients who have experienced different types of trauma

3) Group therapy with patients who have experienced similar traumas This type of group therapy is strongly recommended so that veterans may be able to share experiences with other veterans (and therefore similar traumatic events) to decrease feelings of isolation.

23. Yelling, name-calling, hitting others, and temper tantrums as expressions of anger are all evidence supporting which nursing diagnosis? 1. Risk for self-directed or other-directed violence related to socioeconomic factors 2. Anger related to dysfunctional relationships and ineffective coping skills 3. Ineffective coping related to negative role modeling and dysfunctional family systems 4. Complicated grieving related to a loss of support system

3. This is correct. Clients demonstrating inappropriate expression of anger exhibit ineffective coping related to negative role modeling and dysfunctional family system, evidenced by yelling, name-calling, hitting others, and temper tantrums as expressions of anger.

20. Which initial nursing approach assists clients who are aggressively acting out to accept limit-setting better? 1. Confronting clients with their needs for secondary gains 2. Teaching relaxation techniques 3. Empathizing with the client about the client's distress 4. Presenting appropriate values that need to be modified

3. This is correct. Empathizing with a client promotes a trusting relationship and may prevent the client's anxiety from escalating when limits are set.

19. The client states, "I get into trouble because I respond violently without thinking. That usually gets me into a mess." Which nursing reply is most therapeutic? 1. "Everybody loses their temper. It's good that you know that about yourself." 2. "I'll bet you have some interesting stories to share about overreacting." 3. "Let's explore methods to help you stop and think before taking action." 4. "It's good that you are showing readiness for behavioral change."

3. This is correct. Helping the client identify appropriate problem-solving behaviors and alternative ways to release tension is a therapeutic nursing intervention. Prevention is the key issue in managing aggressive or violent behavior.

11. A client diagnosed with paranoid schizophrenia has a history of aggravated assault. The nurse assigns "Risk for other-directed violence" as the client's priority nursing diagnosis. Which is an appropriate, correctly written outcome for the client? 1. The client will not verbalize anger or hit anyone. 2. The client will verbalize anger rather than hit others. 3. The client will not inflict harm on others during this shift. 4. The client will be restrained if any abuse is observed during this shift.

3. This is correct. Preventing injury to others is the appropriate outcome. Outcomes must be client-centered, specific, realistic, and measurable and contain a time frame.

5. A nurse is caring for four clients. Which client does the nurse identify is least prone to developing problems with anger and aggression? 1. A child raised by a physically abusive parent 2. An adult with a history of epilepsy 3. A young adult living in the ghetto of an inner city 4. An adolescent raised by Scandinavian immigrant parents

4. This is correct. An adolescent raised by Scandinavian immigrant parents would be least prone to developing problems with anger and aggression as compared with the other clients presented.

8. After the client's restraints are removed, the staff discusses the incident and establishes guidelines for the client's return to the therapeutic milieu. Which unit procedure is the staff implementing? 1. Milieu reenactment 2. Treatment planning 3. Crisis intervention 4. Debriefing

4. This is correct. Debriefing following the incident allows the staff the opportunity to express feelings, review, and learn from the experience.

17. A client diagnosed with brief psychotic disorder is pacing the milieu and occasionally punches the wall. Which is the initial nursing action? 1. Assertively instruct the client to stop punching the wall. 2. Encourage the client to write down feelings in a journal. 3. With the help of staff, initiate seclusion protocol. 4. Ensure adequate physical space between the nurse and the client.

4. This is correct. Maintaining client and nurse safety is always the priority. The initial nursing action is to ensure that there is adequate physical space between the nurse and the client. Decreased defensible space and increased contact are related to an increased risk of violence.

24. What is likely to happen if anger is communicated passive-aggressively or aggressively? 1. The individual uses the power to intimidate others. 2. It is discharged against an object or person unrelated to the true target of the anger. 3. Impulsive behavior can result, disregarding possible negative consequences. 4. Conflict escalates, and the problem that created the conflict goes unresolved.

4. This is correct. Passive-aggressive and aggressive responses are likely to escalate conflict.

6. After less-restrictive means have been attempted, an order for client restraints has been obtained for a hostile, aggressive 30-year-old client. If client aggression continues, how long will the nurse expect the client to remain in restraints without a physician order renewal? 1. 1 hour 2. 2 hours 3. 3 hours 4. 4 hours

4. This is correct. The Joint Commission requires that a physician or LIP must reissue a new order for restraints every 4 hours for adults.

A battered woman presents to the emergency department with multiple cuts and abrasions. Her right eye is swollen shut. She says that her husband did this to her. What is the PRIORITY nursing intervention? A) tending to the immediate care of her wounds B) providing her with information about a safe place to stay C) administering the prn tranquilizer ordered by the physician D) explaining how she may go about bringing charges against her husband

A) tending to the immediate care of her wounds

A nursing instructor is teaching students about cirrhosis of the liver. Which of the following student statements about the complications of hepatic encephalopathy should indicate that further student teaching is needed? Select all that apply. A. A diet rich in protein will promote hepatic healing. B. This condition leads to a rise in serum ammonia, resulting in impaired mental functioning. C. In this condition, blood accumulates in the abdominal cavity. D. Neomycin and lactulose are used in the treatment of this condition. E. This condition is caused by the inability of the liver to convert ammonia to urea.

A. A diet rich in protein will promote hepatic healing. C. In this condition, blood accumulates in the abdominal cavity. The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing or that this condition causes blood to accumulate in the abdominal cavity (ascites), because these are incorrect statements. The treatment of hepatic encephalopathy requires abstention from alcohol, temporary elimination of protein from the diet, and reduction of intestinal ammonia by means of neomycin or lactulose. This condition occurs in response to the inability of the liver to convert ammonia to urea for excretion.

A client diagnosed with chronic alcohol use disorder is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching? A. After discharge, the client will immediately attend 90 AA meetings in 90 days. B. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. C. After discharge, the client will incorporate family in AA attendance. D. After discharge, the client will seek appropriate deterrent medications through AA.

A. After discharge, the client will immediately attend 90 AA meetings in 90 days. The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. It accepts alcoholism as an illness and promotes total abstinence as the only cure.

A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family, who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms? A. Between 3 a.m. and 11 a.m. B. Shortly after a 24-hour period C. At the beginning of the third day D. Withdrawal is individualized and cannot be predicted.

A. Between 3 a.m. and 11 a.m. The nurse should expect that this client will begin experiencing withdrawal symptoms from alcohol between 3 a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or reduction in heavy and prolonged alcohol use.

A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess? A. Gross tremors, delirium, hyperactivity, and hypertension B. Disorientation, peripheral neuropathy, and hypotension C. Oculogyric crisis, amnesia, ataxia, and hypertension D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension

A. Gross tremors, delirium, hyperactivity, and hypertension Withdrawal is defined as the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. Symptoms can include gross tremors, delirium, hyperactivity, hypertension, nausea, vomiting, tachycardia, hallucinations, and seizures.

Which of the following nursing statements exemplify important insights that will promote effective intervention with clients diagnosed with substance use disorders? Select all that apply. A. I am easily manipulated and need to work on this prior to caring for these clients. B. Because of my fathers alcoholism, I need to examine my attitude toward these clients. C. Drinking is legal, so the diagnosis of substance use disorder is an infringement on client rights. D. Opiate addicts are typically uneducated, unrefined individuals who will need a lot of education and social skills training. E. I can fix clients diagnosed with substance use disorders as long as I truly care about them.

A. I am easily manipulated and need to work on this prior to caring for these clients. B. Because of my fathers alcoholism, I need to examine my attitude toward these clients. D. Opiate addicts are typically uneducated, unrefined individuals who will need a lot of education and social skills training. The nurse should examine personal bias and preconceived negative attitudes prior to caring for clients diagnosed with substance-abuse disorders. A deficit in this area may affect the nurses ability to establish therapeutic relationships with these clients. A nurse who adopts the attitude that he or she can fix another person may be struggling with codependency issues.

1. What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? A. Risk for injury R/T central nervous system stimulation B. Disturbed thought processes R/T tactile hallucinations C. Ineffective coping R/T powerlessness over alcohol use D. Ineffective denial R/T continued alcohol use despite negative consequences

A. Risk for injury R/T central nervous system stimulation The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

A client diagnosed with depression and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? A. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. B. Sedative-hypnotics are expensive and have numerous side effects. C. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. D. Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.

A. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The effects of central nervous system depressants are additive with one another and are capable of producing physiological and psychological dependence.

A lonely, depressed divorce has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individuals situation? A. The individual is experiencing psychological addiction. B. The individual is experiencing physical addiction. C. The individual is experiencing substance addiction. D. The individual is experiencing social addiction.

A. The individual is experiencing psychological addiction. The nurse should use the term psychological addiction to best describe this clients situation. A client is considered to be psychologically addicted to a substance when there is an overwhelming desire to use a substance in order to produce pleasure or avoid discomfort.

A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the most appropriate reply by the nurse? A. This medication will help you maintain your abstinence. B. This medication will cause uncomfortable symptoms if you combine it with alcohol. C. This medication will decrease the effect alcohol has on your body. D. This medication will lower your risk of experiencing a complicated withdrawal.

A. This medication will help you maintain your abstinence. Campral has been approved by the U.S. Food and Drug Administration (FDA) for the maintenance of abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation.stration (FDA) for the maintenance of abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation.

A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others. The clients parents ask a nurse, Where do the voices come from? Which is the appropriate nursing reply? A. Your child has a chemical imbalance of the brain, which leads to altered thoughts. B. Your childs hallucinations are caused by medication interactions. C. Your child has too little serotonin in the brain, causing delusions and hallucinations. D. Your childs abnormal hormonal changes have precipitated auditory hallucinations.

A. Your child has a chemical imbalance of the brain, which leads to altered thoughts. The nurse should explain that a chemical imbalance of the brain leads to altered thought processes. Hallucinations, or false sensory perceptions, may occur in all five senses. The client who hears voices is experiencing an auditory hallucination.

A child, age 5, is sent to the school nurse's office with an upset stomach. She has vomited and soiled her blouse. When the nurse removes her blouse, she notices that the child has numerous bruises on her arms and torso in various stages of healing. She also notices some small scars, and her abdomen protrudes on her small, thin frame. From the objective physical assessment, the nurse should screen further for : A) physical and sexual abuse B) physical abuse and neglect C) emotional neglect D) sexual and emotional abuse

B) physical abuse and neglect

A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? A. 50 mg/dL B. 100 mg/dL C. 250 mg/dL D. 300 mg/dL

B. 100 mg/dL The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL.

Which is the priority nursing intervention for a client admitted for acute alcohol intoxication? A. Darken the room to reduce stimuli in order to prevent seizures. B. Assess aggressive behaviors in order to intervene to prevent injury to self or others. C. Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system. D. Teach the negative effects of alcohol on the body.

B. Assess aggressive behaviors in order to intervene to prevent injury to self or others. Symptoms associated with the syndrome of alcohol intoxication include but are not limited to aggressiveness, impaired judgment, impaired attention, and irritability. Safety is a nursing priority in this situation.

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediately report to the ED physician? A. Antecubital bruising B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration

B. Blood pressure of 180/100 mm Hg The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day following cessation of prolonged alcohol consumption.

A nurse evaluates a clients patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance use disorder? A. Narcotic pain medication is contraindicated for all clients with active substance-use problems. B. Clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. C. There is no need to assess the client for substance use disorder. There is an obvious PCA malfunction. D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

B. Clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. The nurse should assess the client for substance use disorder because clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. Cross-tolerance occurs when one drug lessens the clients response to another drug.

In assessing a client with polysubstance abuse, the nurse should recognize that withdrawal from which substance may require a life-saving emergency intervention? A. Dextroamphetamine (Dexedrine) B. Diazepam (Valium) C. Morphine (Astramorph) D. Phencyclidine (PCP)

B. Diazepam (Valium) If large doses of a central nervous system (CNS) depressant (such as Valium) are repeatedly administered over a prolonged duration, a period of CNS hyperexcitability occurs on withdrawal of the drug. The response can be quite severe, even leading to convulsions and death.

A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient drug rehabilitation program. Which client statement should a nurse associate with a positive prognosis for this client? A. Im not going to use heroin ever again. I know Ive got the willpower to do it this time. B. I cannot control my use of heroin. Its stronger than I am. C. Im going to get all my children back. They need their mother. D. Once I deal with my childhood physical abuse, recovery should be easy.

B. I cannot control my use of heroin. Its stronger than I am. A positive prognosis is more likely when a client admits that he or she is addicted to a substance and has a loss of control. One of the first steps in the 12-step model for treatment is for the client to admit powerlessness over the substance.

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this clients safety? A. Assess for medication noncompliance B. Note escalating behaviors and intervene immediately C. Interpret attempts at communication D. Assess triggers for bizarre, inappropriate behaviors

B. Note escalating behaviors and intervene immediately The nurse should note escalating behaviors and intervene immediately to maintain this clients safety. Early intervention may prevent an aggressive response and keep the client and others safe.

A client diagnosed with schizophrenia tells a nurse, The Shopatouliens took my shoes out of my room last night. Which is an appropriate charting entry to describe this clients statement? A. The client is experiencing command hallucinations. B. The client is expressing a neologism. C. The client is experiencing a paranoia. D. The client is verbalizing a word salad.

B. The client is expressing a neologism. The nurse should describe the clients statement as experiencing a neologism. A neologism is when a client invents a new word that is meaningless to others but may have symbolic meaning to the client. Word salad refers to a group of words that are put together randomly.

A client with multiple cuts and abrasions arrives at the emergency department with her three small children. She tells the nurse her husband inflicted the wounds. In the interview, she tells the nurse, "He's been getting more and more violent lately. He's been under a lot of stress at work the last few weeks, so he drinks a lot when he gets home. He always gets mean when he drinks. I was getting scared. So I just finally told him I was going to take the kids and leave. He got furious when I said that and began beating me with his fists." With knowledge about the cycle of battering, what does this situation represent? A) Phase I : Attempting to stay out of his way and keep everything calm B) Phase I : A minor battering incident for which she assumes all the blame C) Phase II : The acute battering incident that was provoked by her threat to leave D) Phase III : The honeymoon phase where the husband believes that he has "taught her a lesson and she won't act up again"

C) Phase II : The acute battering incident that was provoked by her threat to leave

A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse? A. Alcohol poisoning B. Cardiovascular accident (CVA) C. A reaction to disulfiram (Antabuse) D. A reaction to tannins in the red wine

C. A reaction to disulfiram (Antabuse) Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good deal of discomfort for the individual. Symptoms may include flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia

3. On the first day of a clients alcohol detoxification, which nursing intervention should take priority? A. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days. B. Educate the client about the biopsychosocial consequences of alcohol abuse. C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. D. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. Chlordiazepoxide (Librium) is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal. Substitution therapy may be required to reduce life-threatening effects of the rebound stimulation of the central nervous system that occurs during withdrawal.

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility? A. By asking directly if the client has ever had a problem with alcohol B. By holistically assessing the client, using the CIWA scale C. By using a screening tool such as the CAGE questionnaire D. By referring the client for physician evaluation

C. By using a screening tool such as the CAGE questionnaire The CAGE questionnaire is a screening tool used to determine whether the individual has a problem with alcohol. This questionnaire is composed of four simple questions. Scoring two or three yes answers strongly suggests a problem with alcohol.

A client with a history of insomnia has been taking chlordiazepoxide (Librium), 15 mg, at night for the past year. The client currently reports that this dose is no longer helping him fall asleep. Which nursing diagnosis appropriately documents this problem? A. Ineffective coping R/T unresolved anxiety AEB substance abuse B. Anxiety R/T poor sleep AEB difficulty falling asleep C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep D. Risk for injury R/T addiction to Librium

C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep

Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply? A. Tell him to stop discussing the voices. B. Ignore what he is saying, while attempting to discover the underlying cause. C. Focus on the feelings generated by the hallucinations and present reality. D. Present objective evidence that the voices are not real.

C. Focus on the feelings generated by the hallucinations and present reality. The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content. It is inappropriate to present logical arguments to persuade the client to accept the hallucinations as not real.

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse? A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader

C. How to make eye contact when communicating The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients in communicating needs and maintaining connectedness.

Upon admission for symptoms of alcohol withdrawal, a client states, I havent eaten in 3 days. Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis? A. Knowledge deficit B. Fluid volume excess C. Imbalanced nutrition: less than body requirements D. Ineffective individual coping

C. Imbalanced nutrition: less than body requirements The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.

A client diagnosed with alcohol use disorder joins a community 12-step program and states, My life is unmanageable. How should the nurse interpret this clients statement? A. The client is using minimization as an ego defense. B. The client is ready to sign an Alcoholics Anonymous contract for sobriety. C. The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous. D. The client has met the requirements to be designated as an Alcoholics Anonymous sponsor.

C. The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous. The first step of the 12-step program advocated by Alcoholics Anonymous is that clients must admit powerlessness over alcohol and that their lives have become unmanageable.

During group therapy, a client diagnosed with alcohol use disorder states, I would not have boozed it up if my wife hadnt been nagging me all the time to get a job. She never did think that I was good enough for her. How should a nurse interpret this statement? A. The client is using denial by avoiding responsibility. B. The client is using displacement by blaming his wife. C. The client is using rationalization to excuse his alcohol dependence. D. The client is using reaction formation by appealing to the group for sympathy.

C. The client is using rationalization to excuse his alcohol dependence The nurse should interpret that the client is using rationalization to excuse his alcohol use disorder. Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior.

A clients wife has been making excuses for her alcoholic husbands work absences. In family therapy, she states, I just need to work harder to get him there on time. Which is the appropriate nursing response? A. Why do you assume responsibility for his behaviors? B. Codependency is a typical behavior of spouses of alcoholics. C. Your husband needs to deal with the consequences of his drinking. D. Do you understand what the term enabler means?

C. Your husband needs to deal with the consequences of his drinking The appropriate nursing response is to use confrontation with caring. In Stage One (The Survival Stage) of recovery from codependency, the codependent person must begin to let go of the denial that problems exist or that his or her personal capabilities are unlimited.

3. The nurse is developing a plan of care for a patient diagnosed with PTSD. Which of the following variables will have an impact on the patient's response to interventions? Select all that apply. 1) Patient's self-esteem 2) Socioeconomic status 3) History of psychopathology 4) Amount of control over recurrence 5) Temperament 6) Immediate crisis debriefing

Correct 1, 2, 3, 4, 5: Each of these has been identified as a variable that impacts the person's response to stressors and trauma. 6: Crisis debriefing is more often used as a preventive strategy and has received mixed reviews about whether it is beneficial for that purpose. Since the patient is already suffering from PTSD, this variable is not relevant to the person's long-term response to the trauma.

15. A patient who has recently been diagnosed with PTSD asks the nurse what his options are for treatment of this disorder. Which of the following items should the nurse include in teaching the patient about primary treatments for PTSD? Select all that apply. 1) Prolonged exposure therapy 2) Cognitive therapy 3) ECT 4) Antipsychotic medication 5) EMDR

Correct 1: Prolonged exposure therapy, in which the patient imagines re-exposure to the trauma with the guidance of a therapist, is a recognized primary treatment for PTSD. Correct 2: Cognitive therapy, in which the patient learns to modify trauma-related thoughts, is a recognized primary treatment for PTSD. Feedback 3: ECT, recognized as a treatment option for depressions that are unresponsive to psychopharmacological and psychological interventions, is not a primary treatment for PTSD. Feedback 4: Antipsychotic medication may be used as an adjunctive treatment to manage significant agitation but is not a primary treatment for PTSD. Correct 5: EMDR (eye movement desensitization and reprocessing) has been shown to be an effective treatment for PTSD.

14. The nurse is conducting an intake assessment for a patient with PTSD. Which of the following pieces of information support this diagnosis? Select all that apply. 1) The patient reports having nightmares but can't remember what they are about. 2) The patient states that he heard a loud noise when he was walking down the street and thought he was back in the war zone where he had last been deployed. 3) The patient took antidepressants when he was in junior high school and reports they didn't help. 4) The patient denies any history of substance abuse or dependence.

Correct 1: This is correct because people suffering from PTSD often complain of nightmares related to the traumatic event but may be amnesic for details of the event. Correct 2: This is correct because people suffering from PTSD often report re-experiencing the trauma. Feedback 3: This piece of information speaks to the patient's history but doesn't necessarily support the diagnosis. However, people suffering from PTSD may be at risk for symptoms of depression and since this person has a history of treatment for depression, it would be important to assess for current symptoms. Feedback 4: Patients sufferings from PTSD often have comorbid substance abuse. The fact that the patient is denying this does not support the diagnosis. However, since it is not uncommon for people with substance abuse issues to deny or minimize their use, it would be important to assess this aspect further.

A school nurse notices bruises and scars on a child's body, but the child refuses to say how she received them. Which of the following is an evidence-based approach for further assessment by the nurse? A) have her evaluated by the school psychologist B) tell her she may select a "treat" from the treat box (e.g., sucker, balloon, junk jewelry) if she answers the nurse's questions C) explain to her that if she answers the questions, she may stay in the nurse's office and not have to go back to class D) use a "family" of dolls to role-play the child's family with her

D) use a "family" of dolls to role-play the child's family with her

Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines? A. Haloperidol (Haldol) and fluoxetine (Prozac) B. Carbamazepine (Tegretol) and donepezil (Aricept) C. Disulfiram (Antabuse) and lorazepam (Ativan) D. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

D. Chlordiazepoxide (Librium) and phenytoin (Dilantin) The nurse should anticipate that a physician would order chlordiazepoxide (Librium) and phenytoin (Dilantin) for a client who has a history of complicated withdrawal from benzodiazepines. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin (Dilantin) is an anticonvulsant that would be indicated for a client who has experienced a complicated withdrawal. Complicated withdrawals may progress to seizure activity.

A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client, Do you receive special messages from certain sources, such as the television or radio? Which potential symptom of this disorder is the nurse assessing? A. Thought insertion B. Paranoia C. Magical thinking D. Delusions of reference

D. Delusions of reference The nurse is assessing for the potential symptom of delusions of reference. A client who believes that he or she receives messages through the radio is experiencing delusions of reference. When a client experiences these delusions, he or she interprets all events within the environment as personal references.

4. Which client statement indicates a knowledge deficit related to substance use? A. Although its legal, alcohol is one of the most widely abused drugs in our society. B. Tolerance to heroin develops quickly. C. Flashbacks from LSD use may reoccur spontaneously. D. Marijuana is like smoking cigarettes. Everyone does it. Its essentially harmless.

D. Marijuana is like smoking cigarettes. Everyone does it. Its essentially harmless. The nurse should determine that the client has a knowledge deficit related to substance use when the client compares marijuana to smoking cigarettes and claims it to be harmless. Both of these substances have potentially harmful effects. Cannabis is the second most widely abused drug in the United States.

A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication? A. Only oral ingestion of alcohol will cause a reaction when taking this drug. B. It is safe to drink beverages that have only 12% alcohol content. C. This medication will decrease your cravings for alcohol. D. Reactions to combining Antabuse with alcohol can occur for as long as 2 weeks after stopping the drug.

D. Reactions to combining Antabuse with alcohol can occur for as long as 2 weeks after stopping the drug. If Antabuse is discontinued, it is important for the client to understand that the sensitivity to alcohol may last for as long as 2 weeks.

6. Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal? A. Antagonist therapy B. Deterrent therapy C. Codependency therapy D. Substitution therapy

D. Substitution therapy A CNS depressant such as Ativan is used during alcohol withdrawal as substitution therapy to prevent life-threatening symptoms that occur because of the rebound reaction of the central nervous system.

Which client statement demonstrates positive progress toward recovery from a substance use disorder? A. I have completed detox and therefore am in control of my drug use. B. I will faithfully attend Narcotic Anonymous (NA) when I cant control my cravings. C. As a church deacon, my focus will now be on spiritual renewal. D. Taking those pills got out of control. It cost me my job, marriage, and children.

D. Taking those pills got out of control. It cost me my job, marriage, and children. A client who takes responsibility for the consequences of substance use is making positive progress toward recovery. This client would most likely be in the working phase of the counseling process, in which he or she accepts the fact that substance use causes problems.

A nurse is interviewing a client in an outpatient drug treatment clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish? A. The client will identify one person to turn to for support. B. The client will give up all old drinking buddies. C. The client will be able to verbalize the effects of alcohol on the body.

D. The client will correlate life problems with alcohol use. To promote the recovery process the nurse should expect that the client would initially correlate life problems with alcohol use. Acceptance of the problem is the first step of the recovery process.

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurses rationale for this intervention? A. To assess for emotional strength B. To assess for Wernicke-Korsakoff syndrome C. To assess for tachycardia D. To assess for fine tremors

D. To assess for fine tremors The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, coarse tremors, and seizure activity.

10. A female patient, Sally, was admitted to the psychiatric inpatient unit with PTSD following a rape 6 months ago in which she suffered several physical injuries. This evening she was approached from behind by a male patient who touched her on the shoulder, and Sally began screaming "I'm going to kill you for what you did to me!" Which of these immediate interventions by the nurse demonstrates a safe and effective care environment? Select all that apply. 1) Place the patient in seclusion for the safety of others. 2) Offer the patient reassurance that she is in a safe environment. 3) Tell the patient to share the details that she remembers about the traumatic event. 4) Stay with the patient. 5) Acknowledge and validate the patient's feelings as they are expressed.

Feedback 1: Seclusion should be used only as a last resort and when there is imminent risk of danger to self or others. There is no evidence that this patient presents such a risk. Correct 2: Since the patient appears to be re-experiencing the trauma, offering reassurance that she is in a safe environment is a priority. Feedback 3: Prompting a patient to share details about the traumatic event at this time, when her anxiety is already heightened, could trigger additional anxiety and negative symptoms. Correct 4: Staying with the patient communicates caring and helps establish trust. Correct 5: Allowing the patient to share feelings at her own pace and validating her feelings as they are expressed will promote an environment for recovery and healing.

11. The nurse is conducting an assessment for a patient diagnosed with PTSD. She recognizes that people with PTSD are at high risk for several comorbid conditions. Which of the following will she need to assess carefully because of the high risk in people with PTSD? Select all that apply. 1) Trichotillomania 2) Depression and suicide ideation 3) Substance abuse 4) Verbal or physical aggression 5) Narcissistic Personality Disorder

Feedback 1: Trichotillomania (Hair Pulling Disorder) is often associated with anxiety disorders, and anxiety is a common symptom in PTSD; however, there is no evidence that trichotillomania is a common response to anxiety in people with PTSD. Correct 2: Depression is a risk for people with PTSD and could become severe enough to warrant diagnosis of a Major Depressive Disorder. This diagnosis carries with it the risk for suicide, so assessment of these two issues is critical for safe, effective care. Correct 3: People suffering from PTSD have a high risk of concurrent substance abuse, so careful assessment of this issue is important to ensure that it is addressed in treatment as needed. Correct 4: Aggression is also a common symptom in people suffering from PTSD. Careful screening for identifiable risks of harm to others is essential to safe, effective care. Feedback 5: Narcissistic Personality Disorder describes a person who has an exaggerated sense of self-worth. This is not common in people with PTSD. It is more common for people with PTSD to describe low self-worth and survivor guilt.

A school nurse notices bruises and scars on a child's body. The nurse suspects that the child is being physically abused. Which action by the nurse is a priority at this point? a. As a health-care worker, report the suspicion to child protective services. b. Check the child again in a week and see if there are any new bruises. c. Meet with the child's parents and ask them how she got the bruises. d. Initiate paperwork to have the child placed in foster care.

a. As a health-care worker, report the suspicion to child protective services.

The nurse is reviewing discharge instructions with a client who is being discharged following a total knee replacement. Knowing that the client has a history of bipolar disorder, the nurse asks the client what needs they perceive they have for follow-up care related to this mental illness. This is an example of : a. Patient-centered care b. Diagnostic overshadowing c. Stigmatization d. Discrimination

a. Patient-centered care

A client presents in the emergency department loudly proclaiming with rapid speech, "If I don't get more pain medication right now, I'm going to call the attorney general and sue the entire health-care network." Which of the following should be included in initial screening and assessment? (Select all that apply) a. substance abuse b. pain c. mental illness d. prior history of convictions e. availability of an inpatient psych bed

a. substance abuse b. pain c. mental illness

A client was admitted to the intensive care unit after a single-car accident in which he struck a cement wall. He is now responsive and wants to be discharged within the next couple of days. Which of the following are priorities for screening? (Select all that apply) a. traumatic brain injury b. chronic pain c. sexual dysfunction d. depression and risk for suicide

a. traumatic brain injury d. depression and risk for suicide

A college-age client is brought to the emergency department by her roommate after she confided that she was raped by her date who invited her to a frat party. The client says to the nurse, "It's all my fault. I shouldn't have gone to a party where I knew there was going to be alcohol." Which of these is the best response by the nurse? a. "Yes, you're right. You put yourself in a very vulnerable position when you allowed him to get you drunk." b. "You are not to blame for his behavior. You obviously made some right decisions, because you survived the attack." c. "There's no sense looking back now. Just look forward, and make sure you don't put yourself in the same situation again." d. "You'll just have to see that he is arrested so he won't do this to anyone else."

b. "You are not to blame for his behavior. You obviously made some right decisions, because you survived the attack."

A client arrives at the emergency department and tells the nurse her husband inflicted the cuts to her face that required sutures. She said, "I didn't want to come. I'm really okay. He only does this when he has too much to drink. I just shouldn't have yelled at him." The best response by the nurse is : a. "How often does he drink too much?" b. It is not your fault. You did the right thing by coming here." c. How many times has he done this to you? d. He is not a good husband. You have to leave him before he kills you."

b. It is not your fault. You did the right thing by coming here."

A young man who has just undergone a sexual assault is brought into the emergency department by a friend. What is the PRIORITY nursing intervention? a. Help him to bathe and clean himself up. b. Provide physical and emotional support during evidence collection. c. Provide him with a written list of community resources for survivors of rape. d. Discuss the importance of a follow-up visit to evaluate for sexually transmitted diseases.

b. Provide physical and emotional support during evidence collection.

The nurse manager recognizes a need to improve mental health and substance use screening and referral services for their clients in the public health clinic. Which of the following is a priority to begin an effective process for implementation? a. provide a list of referral sources that are readily available to staff b. educate staff about the importance of prioritizing these public health concerns c. explore the literature for evidence based screening tools d. inform the staff that they have been stigmatizing patients and this will not be tolerated

b. educate staff about the importance of prioritizing these public health concerns

A client enters the emergency department and reports, "My bed is on fire, and my stomach, and we're all dead." The nurse's initial response is to call the psychiatric unit to secure an inpatient bed for this patient. The nurse's action is an example of: a. Prompt, appropriate referral b. Patient-centered care c. Stigmatization d. Collaboration

c. Stigmatization

16. One type of intervention useful for patients with adjustment disorders is a short-term therapy focused on problem-solving skills and restoring adaptive functioning. This type of therapy is ____________________.

crisis intervention The goal of this therapy is to mobilize resources needed to resolve the crisis situation. It is relevant in the treatment of adjustment disorders since a lack of adequate coping skills and resources contributes to the development of this condition.

A woman who has a long history of being battered by her husband is staying at the woman's shelter. She has received emotional support from staff and peers and has been made aware of the alternatives open to her. Nevertheless, she decides to return to her home and marriage. The best response by the nurse to the woman's decision is : a. "I just can't believe you have decided to go back to that horrible man." b. "I'm just afraid he will kill you or the children when you go back." c. "What makes you think things have changed with him?" d. "I hope you have made the right decision. Call this number if you need help."

d. "I hope you have made the right decision. Call this number if you need help."

Screening for substance use and suicide risk should be conducted in which of the following settings? a. Emergency department b. Primary care settings c. Medical units d. All of the above

d. All of the above

One of the outcomes of diagnostic overshadowing in clients with mental illness is : a. Better quality of life b. Increased access to resources c. More comprehensive care d. Increased risk for death

d. Increased risk for death

The nurse is providing education to a support group for survivors of rape. Which of the following items is evidence-based information to include in this teaching? a. Rapists typically drink alcohol and are not in control of their actions b. Rape is usually an event that occurs between two people who are sexually frustrated c. Men who are born into poverty are predisposed to becoming rapists after puberty d. Rape is an expression of power and dominance by means of sexual aggression and violence

d. Rape is an expression of power and dominance by means of sexual aggression and violence

A client on a medical unit is identified to be having suicidal ideation. Which of the following is a priority in managing his immediate care? a. screen for depression b. provide sedative medication c. refer him to another setting d. continuous monitoring and observation

d. continuous monitoring and observation