HESI PN Mental Health Exam Prep Questions & Knowledge Review

A nurse is evaluating a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident? 1. 2 years 2. 6 years 3. 6 months 4. 1 to 3 months

1. 2 years By 2 years of age the child should demonstrate an interest in others, communicate verbally, and possess the ability to learn from the environment. Before the age when these skills develop, autism is difficult to diagnose. Usually by 3 years the signs of autism become more profound. Autism can be diagnosed long before a child is 6 years old. Infantile autism may occur in an infant of 1 to 3 months, but at this age it is difficult to diagnose.

Which of these are symptoms of depression commonly observed in older adults? Select all that apply. 1. Fatigue 2. Sadness 3. Agitation 4. Increased sleep 5. Increased appetite

1. Fatigue 2. Sadness 3. Agitation Symptoms of depression that are often observed in older adults include fatigue, sadness, and agitation. Insomnia is more likely than increased sleep to occur in depressed older adults. Anorexia, rather than increased appetite, is more likely to occur in depressed older adults.

Which is a symptom of generalized anxiety? 1. Insomnia 2. Pessimism 3. Hot flashes 4. Limited attention span

1. Insomnia Insomnia is a symptom of generalized anxiety. Pessimism and limited attention span are symptoms of major depression. Hot flashes are a symptom of a panic attack.

Which subtypes of schizophrenia have a poor prognosis? Select all that apply. 1. Residual 2. Paranoid 3. Catatonic 4. Disorganized 5. Undifferentiated

1. Residual 4. Disorganized The residual and disorganized subtypes of schizophrenia each have a poor prognosis. The prognosis of paranoid schizophrenia is good with treatment. The prognoses of the catatonic and undifferentiated subtypes of schizophrenia are fair.

One morning a nurse on the psychiatric unit finds a client curled up in the fetal position in the corner of the dayroom. What is an appropriate initial inference for the nurse to make about the client? 1. The client is feeling more anxious today. 2. The client is trying to hide from the staff. 3. The client is tired and probably did not sleep well last night. 4. The client is physically ill and experiencing abdominal discomfort.

1. The client is feeling more anxious today. The fetal position represents regressive behavior; regression is a way of responding to overwhelming anxiety. No data are available to indicate that the client is trying to hide or is tired or physically ill; further assessment would be necessary to support these other interpretations.

What is the most commonly experienced type of hallucination? 1. Visual 2. Tactile 3. Auditory 4. Olfactory

3. Auditory Auditory hallucinations are the most commonly experienced type of hallucinations. Visual, tactile, and olfactory hallucinations are less commonly experienced compared to auditory ones.

Which drug is a high-potency medication used to treat schizophrenia? 1. Loxapine 2. Thioridazine 3. Fluphenazine 4. Perphenazine

3. Fluphenazine Fluphenazine is a high-potency medication used for schizophrenia. Loxapine and perphenazine are medium-potency medications used to treat schizophrenia. Thioridazine is a low-potency medication used to treat schizophrenia.

What characteristic of the environment is most therapeutic for clients with the diagnosis of bulimia nervosa? 1. Controlling 2. Empathetic 3. Focused on food 4. Based on realistic limits

4. Based on realistic limits Realistic guidelines reduce anxiety, increase feelings of security, and increase adherence to the therapeutic regimen. A controlling environment sets up a power struggle between these clients and the nurse. These clients need realistic rules and regulations that they identify as helpful, not empathy. Focusing on food is not therapeutic; focusing on food may result in a power struggle between these clients and the nurse.

A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified (autistic disorder). What should the nurse consider most unusual for the child to demonstrate? 1. Interest in music 2. Ritualistic behavior 3. Attachment to odd objects 4. Responsiveness to the parents

4. Responsiveness to the parents One of the symptoms that an autistic child displays is lack of responsiveness to others; there is little or no extension to the external environment. Music is nonthreatening, comforting, and soothing. Repetitive behavior provides comfort. Repetitive visual stimuli, such as a spinning top, are nonthreatening and soothing.

A client comes to the mental health clinic for a monthly intramuscular 37.5 mg fluphenazine decanoate injection. Fluphenazine decanoate is available 25 mg/mL. How many milliliters of solution should the nurse administer? Record your answer using one decimal place. __________ mL

Use the "desired over have" formula of ratio and proportion. Desire 37.5 mg x mL ------------------- = ------ Have 25 mg 1 mL 25x = 37.5 x = 37.5 ÷ 25 x = 1.5 mL

A client has just been admitted with the diagnosis of borderline personality disorder. There is a history of suicidal behavior and self-mutilation. What does the nurse remember is the main reason that clients use self-mutilation? 1. To control others 2. To express anger or frustration 3. To convey feelings of autonomy 4. To manipulate family and friends

2. To express anger or frustration Typically, recurrent self-mutilation is an expression of intense anger, helplessness, or guilt or is a form of self-punishment. Self-mutilation is used not to control others but for self-validation; also, it is a means of blocking psychological pain by inducing physical pain. Self-destructive behaviors are not an expression of autonomy but rather an expression of negative feelings of anger, rage, and abandonment. Self-destructive behaviors represent not an attempt to manipulate others but rather a way to blunt emotional pain.

A client on a psychiatric unit misses breakfast because of an elaborate hand-washing ritual. What is the most important therapeutic intervention during the early period of the client's hospitalization? 1. Having the client wait until after breakfast to start the ritual 2. Waking the client early so the ritual can be completed before breakfast 3. Encouraging the client to interrupt the ritual for meals at the scheduled times 4. Allowing the client to choose between eating breakfast and completing the ritual

2. Waking the client early so the ritual can be completed before breakfast In the early part of treatment, before new defenses are developed, time must be allowed for the client to complete the ritual to keep anxiety under control. The ritual is a defense that cannot be interrupted or delayed; it is used until new defenses are developed.

A nurse is aware that after the administration of alprazolam (Xanax) is started, it is important to observe the client for side effects. What is the nurse's initial action? 1. Measuring the client's urine output 2. Examining the client's pupils daily 3. Checking the client's blood pressure 4. Monitoring the abdomen for distention

3. Checking the client's blood pressure Orthostatic hypotension is a common side effect of alprazolam (Xanax) that occurs early in therapy. Central nervous system depression is not an early side effect, but it may occur after prolonged use. An alteration in urine output is not a common side effect, but it may occur after prolonged use. Distention is not a common side effect, but distention from constipation may occur after prolonged use.

A nurse sits with a depressed client twice a day, but there is little verbal communication. One afternoon the client asks, "Do you think they'll ever let me out of here?" What is the best reply by the nurse? 1. "We should ask your doctor." 2. "Everyone says you're doing fine." 3. "Do you think you're ready to leave?" 4. "How do you feel about leaving here?"

4. "How do you feel about leaving here?" The nurse's response urges the client to reflect on feelings and encourages communication. "We should ask your doctor?" shifts responsibility from the nurse to the health care provider; it is an evasive response. "Everyone says you're doing fin?" is not what the client is asking the nurse; it closes the door to further communication. "Do you think you're ready to leave?" may elicit a yes or no answer; it does not encourage communication.

When planning activities for a child with autism, the nurse remembers that autistic children respond best to which activities? 1. Loud, cheerful music 2. Large-group activities 3. Individuals in small groups 4. Their own self-stimulating acts

4. Their own self-stimulating acts Autistic behavior turns inward. Autistic children do not respond to the environment; instead, they attempt to maintain emotional equilibrium by rubbing and manipulating themselves and display a compulsive need for behavioral repetition. Autistic children do seem to respond to music, but not necessarily loud, cheerful music. Large-group (or small-group) activity has little effect on the autistic child's response. Part of the autistic pattern is the inability to interact with others in the environment, regardless of the size of the group.

Which class of drugs is frequently prescribed for a client with bipolar disorder to induce sedation? 1. Antipsychotics 2. Antidepressants 3. Benzodiazepines 4. Mood stabilizers

Benzodiazepines are frequently used to sedate clients with bipolar disorder (BPD). BPD is treated with three major classes of drugs which include mood stabilizers, antipsychotics, and antidepressants.

A client in a detoxification unit has an alcohol withdrawal seizure. Diazepam (Valium) 7.5 mg intramuscularly stat is prescribed. Valium is available 5 mg/mL. How many milliliters should the nurse administer? Record your answer using one decimal place. __________ mL

Solve for x with the "desire over have" formula of ratio and proportion. Desire 7.5 mg x mL -------------- = ----- Have 5 mg 1 mL 5x = 7.5 x = 7.5 5 x = 1.5 mL

Which mental disorder is considered a thought process disorder? 1. Depression 2. Schizophrenia 3. Panic disorder 4. Obsessive-compulsive disorder

The mental disorder schizophrenia is considered a thought process disorder. Depression is a mental health disorder that is considered a mood disorder. Panic disorder and obsessive-compulsive disorder are considered anxiety disorders.

Which cognitive impairment occurs due to delirium? 1. Attentiveness 2. Concentration 3. Thought process 4. Abstract thinking

1. Attentiveness Impairment of attentiveness can occur due to delirium. Impairment of concentration and impairment of thought process both occur due to depression. Impairment of abstract thinking occurs due to dementia.

A nurse in a mental health facility is caring for a client with the diagnosis of borderline personality disorder. What should the nurse plan to do to maintain a therapeutic relationship? 1. Be firm, consistent, and understanding because there is a need for structure 2. Provide an informal environment because the client seeks outlets for self-expression 3. Use an authoritarian approach because the client must learn to conform to the rules of society 4. Ignore marked shifts in mood, suicidal threats, and temper displays because they are short lived

1. Be firm, consistent, and understanding because there is a need for structure Consistency, limit-setting, and supportive confrontation are essential nursing interventions to foster a secure, therapeutic environment. An informal environment is not therapeutic because it supports impulsive behavior and impedes a change in behavior. The use of an authoritarian approach will increase anxiety, resulting in feelings of rejection and withdrawal. Ignoring the behavior is nontherapeutic and reinforces underlying fears of abandonment.

A client reports dizziness, nausea, and chills. On assessment, the nurse finds that the client is trembling and sweating, has an accelerated heart rate, and fears losing control and choking. Which medication would be beneficial in relieving the client's condition? 1. Buspirone 2. Olanzapine 3. Amitriptyline 4. Divalproex sodium

1. Buspirone Dizziness, nausea, chills, trembling, sweating, accelerated heart rate, and a fear of losing control and choking indicate that the client is having a panic attack. Panic disorder is an anxiety disorder, and antianxiety agents such as buspirone can be used to treat the client's condition. Olanzapine is used to treat schizophrenia. Amitriptyline is used to treat major depression. Divalproex sodium is used to treat mania and mood disorders.

In which mood disorder are there repeated swings between hypomania and depression? 1. Cyclothymic disorder 2. Postpartum depression 3. Major depression 4. Seasonal affective disorder

1. Cyclothymic disorder Cyclothymic disorder is characterized by repeated mood swings between hypomania and depression. Postpartum depression is a period of depression following childbirth and does not feature hypomanic episodes. Major depression is characterized by long periods of intense unhappiness without hypomanic episodes, and seasonal affective disorder occurs in the winter months with periods of depression that do not alternate with hypomanic episodes.

Which herb may improve memory and boost energy? 1. Ginkgo 2. Gotu kola 3. Rosemary 4. Cedarwood

1. Ginkgo Ginkgo (Ginkgo biloba) and ginseng improve memory and boost energy. Gotu kola is useful in treating anxiety. Rosemary and cedarwood may help relieve stress and achieve mental balance.

A health care provider diagnoses attention deficit hyperactivity disorder (ADHD) in a 7-year-old child and prescribes methylphenidate (Ritalin). The nurse discusses the child's treatment with the parents. What should the nurse emphasize as important for the parents to do? 1. Monitor the effect of the medication on their child's behavior 2. Increase or decrease the dosage, depending on the child's behavior 3. Avoid imposing too many rules, because this will frustrate the child 4. Point out to their child that he can control this behavior if he wants to

1. Monitor the effect of the medication on their child's behavior By monitoring and reporting changes in the child's behavior, the heath care provider can determine the effectiveness of the medication. Dosage changes are the responsibility of the health care provider. Children need structure and rules; they provide a sense of security. Behavior is not deliberate or controllable; this statement may diminish the child's self-esteem if he or she cannot exert control.

An older depressed person at an independent living facility constantly complains about her health problems to anyone who will listen. One day the client says, "I'm not going to any more activities. All these old crabby people do is talk about their problems." What defense mechanism does the nurse conclude that the client is using? 1. Projection 2. Introjection 3. Somatization 4. Rationalization

1. Projection The client is assigning to others those feelings and emotions that are unacceptable to him- or herself. Introjection is treating something outside the self as if it is inside the self. Somatization is the unconscious transformation of anxiety into a physical symptom that has no organic cause. Rationalization is the use of a socially acceptable logical explanation to justify personally unacceptable material.

A 17-year-old client is found to have anorexia nervosa. The psychiatrist, in conjunction with the client and the parents, decides to institute a behavior modification program. What does the nurse recall is a major component of behavior modification? 1. Rewarding positive behavior 2. Reducing necessary restrictions 3. Deconditioning fear of weight gain 4. Reducing anxiety-producing situations

1. Rewarding positive behavior In behavior modification, positive behavior is reinforced, and negative behavior is neither reinforced nor punished. Reducing the number or complexity of necessary restrictions, deconditioning the fear of weight gain, and reducing the number of anxiety-producing situations may all be part of the program, but none is a major component.

What childhood problem has legal as well as emotional aspects and cannot be ignored? 1. School phobia 2. Fear of animals 3. Fear of monsters 4. Sleep disturbances

1. School phobia School phobia is a disorder that cannot legally be ignored for long because children must attend school. It requires intervention to alleviate the separation anxiety and promote the child's increasing independence. Fear of animals and monsters and sleep disturbances all require parents to comfort the child, to reorient the child to reality, and to help the child regain self-control. Legally there are no requirements mandating treatment for these common childhood problems.

A client with paranoid schizophrenia tells the nurse, "My neighbors are spying on me because they want to rob me and take money." While hospitalized, the client complains of being poisoned by the food and of being given the wrong medication. The nurse evaluates the client's response to medications and therapy. Which finding leads the nurse to conclude that the client's reality testing has improved? 1. The client eats the food provided on the hospital tray. 2. The client discusses his discharge plans with the staff. 3. The client questions each medication when it is administered. 4. The client asks permission to make phone calls to the hospital administration.

1. The client eats the food provided on the hospital tray. Because the client was complaining during her hospital stay that the food was poisoned, eating the food on the tray indicates that the client feels safe and understands that the hospital staff is not poisoning her food. Discussing discharge plans with the staff does not provide adequate behavioral assessment with which the nurse can evaluate reality testing. Questioning each medication when it is administered indicates that the client still does not completely trust the staff. Asking permission to make phone calls to the hospital administration seems to indicate that the client still does not trust the staff and is attempting to intimidate the staff by calling the administration.

A nurse is caring for a client with the diagnosis of schizophrenia. What is a common problem for clients with this diagnosis? 1. Chronic confusion 2. Disordered thinking 3. Rigid personal boundaries 4. Violence directed toward others

2. Disordered thinking The individual with schizophrenia has neurobiological changes that cause disorders in thought process and perceiving reality. Chronic confusion and disorientation are not usually associated with this disorder. Illogical thinking and impaired judgment are associated with schizophrenia. Individuals with the diagnosis of schizophrenia often have personal boundary difficulties. They lack a sense of where their bodies end in relation to where others begin. Loss of ego boundaries can result in depersonalization and derealization. Most clients with schizophrenic disorders are not violent.

What is a warning sign of suicide? 1. Sleeping soundly 2. Giving away prized possessions 3. Spending more time with family 4. Complaining about physical problems with organic causes

2. Giving away prized possessions One warning sign of suicide is the giving away of prized possessions. Disturbance of sleep patterns, rather than sound sleep, is a warning sign of suicide. The suicidal client withdraws from family or friends rather than spending more time with them. The suicidal client may complain about physical problems with no organic causes rather than about problems with organic causes.

Which subtype of schizophrenia may have good prognosis with treatment? 1. Residual 2. Paranoid 3. Catatonic 4. Disorganized

2. Paranoid The prognosis of paranoid schizophrenia is good with treatment. The residual subtype of schizophrenia may have a poor prognosis. The prognosis of the catatonic subtype of schizophrenia is fair. The prognosis of disorganized schizophrenia is poor with treatment.

Many clients who call a crisis hotline are extremely anxious. The nurse answering the hotline phone considers that which characteristic distinguishes posttraumatic stress disorders from other anxiety disorders? 1. Lack of interest in family and others 2. Reexperiencing the trauma in dreams and flashbacks 3. Avoidance of situations and activities that resemble the stress 4. Depression and a blunted affect when discussing the traumatic situation

2. Reexperiencing the trauma in dreams and flashbacks Experiencing the actual trauma in dreams or flashbacks is the major symptom that distinguishes posttraumatic stress disorders from other anxiety disorders. Lack of interest in family and others is usually not associated with anxiety disorders. Avoidance of situations and activities that resemble the stress is more common with phobic disorders. Although depression may be generated by discussion of the traumatic situation, the affect is usually exaggerated, not blunted.

Which client statement supports the diagnosis of somatic delusions? 1. "I wear this coat all the time to keep them from x-raying my organs." 2. "The president of France and I will be announcing our engagement soon." 3. "My heart stopped beating 3 days ago, and now my lungs are rotting away." 4. "The government has assigned a team of assassins to kill me because I know too much."

3. "My heart stopped beating 3 days ago, and now my lungs are rotting away." A somatic delusion is a belief that the body is changing or behaving in an unusual way (e.g., the client's heart stopping and the lungs rotting away). Erotomanic delusions are focused on the belief that another person (usually famous or otherwise unattainable) is romantically interested in the client. Control delusions center on the belief that others are attempting to control or affect the person in some manner. Persecutory delusions involve beliefs that one is being singled out for harm.

On the day after admission a suicidal client asks a nurse, "Why am I being watched around the clock, and why can't I walk around the whole unit?" Which reply is most appropriate? 1. "Why do you think we're observing you?" 2. "What makes you think we're observing you?" 3. "We're concerned that you might try to harm yourself." 4. "We're following your doctor's instructions, so there must be a reason."

3. "We're concerned that you might try to harm yourself." The statement "We're concerned that you might try to harm yourself." is honest and helps establish trust. Also, it may help the client realize that the staff members care. "Why do you think we're observing you?" will put the client on the defensive. "What makes you think we're observing you?" is an inappropriate response when the answer is so obvious. The response "We're following your doctor's instructions, so there must be a reason." is evasive.

Which disorders are complications associated with alcoholism? Select all that apply. 1. Rhinitis 2. Sinusitis 3. Delirium tremens 4. Korsakoff psychosis 5. Wernicke encephalopathy

3. Delirium tremens 4. Korsakoff psychosis 5. Wernicke encephalopathy Delirium tremens, Korsakoff psychosis, and Wernicke encephalopathy are associated with alcoholism. Rhinitis and sinusitis are associated with chronic abuse of cocaine by snorting.

In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by the police, who were called when she barricaded herself in a ladies' restroom of a restaurant. During admission the client shouts, "Don't come near me! My stomach is filled with bombs, and I'll blow up this place if anyone comes near me." What does the nurse conclude that the client is exhibiting? 1. Ideas of reference 2. Loose associations 3. Delusional thinking 4. Tactile hallucinations

3. Delusional thinking Delusions are false fixed beliefs that have a minimal basis in reality. This is a somatic delusion. Ideas of reference are false beliefs that every statement or action of others relates to the individual. Loose associations are verbalizations that sound disjointed to the listener. Tactile hallucinations are false sensory perceptions of touch without external stimuli.

A male client in a mental health facility turns his head to the side during a unit meeting as if he hears something. When the nurse comments about it, the client replies, "You know, it's that microcomputer those foreign agents implanted in my ear." In light of this statement, what does the nurse determine that the client is experiencing? 1. Illusions 2. Hallucinations 3. Delusional thoughts 4. Neologistic thinking

3. Delusional thoughts The client's statement reveals the cognitive disturbance called a delusion, which is a fixed set of false beliefs that cannot be corrected by reason. An illusion is a misperception of an actual environmental stimulus. A hallucination is a sensory experience, unrelated to external stimuli. Neologisms are made-up words understood only by the speaker.

Which personality disorder is characterized by anxious, fearful behavior? 1. Schizoid personality disorder 2. Antisocial personality disorder 3. Dependent personality disorder 4. Narcissistic personality disorder

3. Dependent personality disorder Dependent personality disorder is in the fearful cluster of personality disorders, and is characterized by anxious, fearful behavior. Schizoid personality disorder is characterized by odd or eccentric behavior. Antisocial personality disorder and narcissistic personality disorder are characterized by dramatic, emotional, or erratic behavior.

A 20-year-old carpenter falls from a roof and sustains fractures of the right femur and left tibia. The client reveals a history of substance abuse. What is the primary consideration for the nurse who is caring for this client? 1. Confronting the client about substance abuse 2. Avoiding calling attention to the client's drug abuse 3. Determining the amount and time of last use of the substance 4. Realizing that this client will need more pain medication than a nonabuser

3. Determining the amount and time of last use of the substance Determining the amount and last use of the substance is the priority. Nurses should base their treatment of withdrawal symptoms based on the time and amount of last use. Confronting the client is not the nurse's responsibility at this time. The client must be helped to recognize that a problem with drugs exists. Because of cross-tolerance the client may need larger doses of analgesia for pain relief than a nonabuser would.

A client with the diagnosis of bipolar disorder, manic episode, is extremely active, talks constantly, and tends to badger the other clients, some of whom are becoming agitated. What is the best strategy for a nurse to use with this client? 1. Humor 2. Sympathy 3. Distraction 4. Confrontation

3. Distraction During periods of hyperactivity the client has a short attention span and can be distracted easily; distraction will serve as a therapeutic intervention for all of the clients. The nurse should be empathetic, not sympathetic. Humor and confrontation may each worsen anxiety, increase activity, and aggravate aggressive behavior.

Which herb used in the treatment of Alzheimer's disease lowers the blood glucose level? 1. Kava 2. Gotu kola 3. Ginseng 4. St. John's wort

3. Ginseng Ginseng provides cognitive improvement in the treatment of early Alzheimer's disease. Ginseng also sometimes lowers blood glucose. Kava is used to treat anxiety and insomnia. Gotu kola is used by ayurvedic practitioners to help clients reduce anxiety. St. John's wort is used in treating mild depression. Kava, gotu kola, and St. John's wort do not lower blood sugar.

A client with a conversion disorder is experiencing paralysis of a leg. What can the nurse expect from this client? 1. The client may experience a spread of the paralysis to other body parts 2. The client may require continuous psychiatric treatment to maintain independent function 3. The client may recover use of the affected leg but, under stress, to again experience these symptoms 4. The client may follow an unpredictable emotional course in the future, depending on exposure to stress

3. The client may recover use of the affected leg but, under stress, to again experience these symptoms The conversion type of defense tends to be a learned behavioral response that the individual will use when experiencing excessive stress. A spread of the paralysis to other body parts is not likely. Psychiatric treatment may be needed at different times throughout life but usually not on a continuous basis. Studies of this disorder have revealed that its course is somewhat predictable; it usually returns when the client is under severe stress.

A client with schizophrenia is unable to feel happiness and joy. What is the name of this condition? 1. Alogia 2. Apathy 3. Flat affect 4. Anhedonia

4. Anhedonia Anhedonia is the inability to experience happiness or joy. It is a negative behavior associated with schizophrenia. Alogia is defined as reduced content of speech. Apathy is a lack of energy or interest. Flat affect is the lack of nonverbal expression of emotions, such as facial expression or tone of voice.

A client with a long history of alcohol dependence spends 28 days in an alcohol-rehabilitation unit. What type of referral does the nurse anticipate will be included in the discharge plan? 1. Halfway house 2. Family therapist 3. Psychoanalytic therapy group 4. Community-based self-help group

4. Community-based self-help group Referral to a community-based self-help group is an essential component of the discharge plan to provide ongoing support. The client probably does not need a halfway house. Although some forms of therapy may be helpful, the most successful intervention for alcohol abuse is Alcoholics Anonymous.

A nurse administers prescribed anxiolytics to clients with severe emotional disorders. What is the goal of this treatment? 1. Reduces antisocial symptoms 2. Limits secondary complications 3. Prevents destructiveness by the client 4. Makes the client more amenable to psychotherapy

4. Makes the client more amenable to psychotherapy Anxiolytics reduce the anxiety level and make clients more open to new strategies when coping with stress. Anxiolytics do not ease antisocial symptoms. They cannot prevent secondary complications. Preventing destructiveness by the client is not the major reason for their administration.

Which drugs are considered neuroleptics? Select all that apply. 1. Asenapine 2. Lurasidone 3. Aripiprazole 4. Thioridazine 5. Chlorpromazine

4. Thioridazine 5. Chlorpromazine First-generation antipsychotic drugs are also known as neuroleptics. Thioridazine and chlorpromazine are neuroleptics. Asenapine, lurasidone, and aripiprazole are second-generation drugs, which are considered as atypical antipsychotic drugs.

In which type of delusion does a client believe that thoughts are being removed from his or her mind? 1. Grandeur 2. Persecution 3. Thought insertion 4. Thought withdrawal

4. Thought withdrawal Thought withdrawal is a type of delusion in which the client believes that thoughts are being removed from his or her mind. In a grandeur type of delusion, the client believes that he or she has great powers to control any situation. In a persecution-type delusion, the client believes that someone is out to harm him or her. In a thought-insertion delusion, the client believes that ideas are being put in his or her mind.

What are the symptoms of major depression? Select all that apply. 1. Apathy 2. Insomnia without fatigue 3. Mood swings with manic episodes 4. Guilt feelings 5. Sleep disturbances

1. Apathy 4. Guilt feelings 5. Sleep disturbances Apathy, guilt feelings, and sleep disturbances are symptoms of major depression. Insomnia without fatigue and mood swings with manic episodes are symptoms of bipolar affective disorder.

Which side effect may be experienced by a client taking an antianxiety agent? 1. Ataxia 2. Akathisia 3. Dyspepsia 4. Leukopenia

1. Ataxia Ataxia is a side effect of antianxiety agents. Akathisia is a side effect of antipsychotic agents. Dyspepsia is a side effect of atypical antipsychotic agents. Leukopenia is an adverse effect of some antipsychotic agents.

What drug should a nurse anticipate that the health care provider will prescribe for a client demonstrating clinical manifestations associated with an opioid overdose? 1. Naloxone 2. Methadone 3. Epinephrine 4. Amphetamine

1. Naloxone Naloxone is a narcotic antagonist that displaces opioids from receptors in the brain, thereby reversing respiratory depression. Methadone is a synthetic opioid that causes central nervous system depression; it will add to the problem of overdose. Epinephrine and amphetamine will have no effect on respiratory depression related to opioid overdose.

A depressed client has been sitting alone in a chair most of the day and displays no interest in eating. How should the nurse plan to meet this client's nutritional needs? 1. Stay with the client during meals 2. Take the client to the dining room 3. Bring the client a tray of finger foods 4. Talk with the client about the importance of nutrition

1. Stay with the client during meals Active support is demonstrated when the nurse sits with the client during meals. Even if taken to the dining room, a depressed client may lack the physical or emotional energy to eat. Finger foods are more effectively given to clients experiencing mania. Discussing the importance of nutrition is too passive an intervention for a depressed client and usually will not stimulate the client to take action or change eating behaviors.

Which nursing intervention is indicated for a client with an anxiety disorder? 1. Encouraging suppression of anger by the client 2. Promoting verbalization of feelings by the client 3. Limiting involvement of the client's family during the acute phase 4. Explaining why the client should accept the psychological factors that are precipitating the anxiety

2. Promoting verbalization of feelings by the client Freedom to express feelings serves as a safety valve to reduce anxiety. Suppression of anger or hostility may add to the client's anxiety. Limiting involvement of the client's family during the acute phase may or may not be helpful; the client's family members may provide support. Explaining why the client should accept the psychological factors that are precipitating the anxiety is not therapeutic; accepting current situational stresses may not be possible.

A nurse is caring for a client admitted to a mental health unit because of suicidal ideation. Which intervention provides the greatest safety for this client? 1. Seclusion room 2. Four-point restraints 3. Constant one-to-one supervision 4. Removal of unsafe objects from the environment

3. Constant one-to-one supervision A member of the health team provides a continuous presence to ensure the safety of a client who is at high risk for suicide. Although removing unsafe objects from the environment is important, clients who are intent on self-harm will find ways even if such objects are removed. Seclusion and four-point restraints are overly restrictive.

What is the greatest difficulty for nurses caring for the severely depressed client? 1. Client's lack of energy 2. Negative cognitive processes 3. Contagious quality of depression 4. Client's psychomotor retardation

3. Contagious quality of depression Depression is contagious; it affects the nurse as well as the client. The client's lack of energy does not make nursing care difficult. Intervening with the client's negative thinking is an expected part of nursing care and does not create special difficulties for the nurse. The client's lack of energy does not make nursing care difficult.

Which qualities are traits of an addictive personality? Select all that apply. 1. Confusion 2. Illogical thinking 3. Negative self-image 4. Feelings of insecurity 5. Low tolerance for stress

3. Negative self-image 4. Feelings of insecurity 5. Low tolerance for stress Negative self-image, feelings of insecurity, and low tolerance for stress are traits of the addictive personality. Confusion and illogical thinking are alcohol withdrawal symptoms.

A nurse is caring for a group of children with the diagnosis of autism. Which signs and symptoms are associated with this disorder? Select all that apply. 1. Lack of appetite 2. Depressed mood 3. Repetitive activities 4. Self-injurious behaviors 5. Lack of communication with others

3. Repetitive activities 4. Self-injurious behaviors 5. Lack of communication with others Perseveration (repetition of a behavior pattern) is commonly demonstrated by children with autism; this behavior provides comfort. Self-stimulation through injurious behavior is associated with autism. Children with autism have difficulty communicating or do not communicate at all with others. There may be unusual eating habits and food preferences, but lack of appetite is not associated with autism. Mood disorders are usually not associated with autism.

It is determined that a staff nurse has a drug abuse problem. What should happen as an initial intervention? 1. The staff nurse should be counseled by the staff psychiatrist 2. The staff nurse should be dismissed from the job immediately 3. The staff nurse should be referred to the employee assistance program 4. The staff nurse should be forced to promise to abstain from drugs in the future

3. The staff nurse should be referred to the employee assistance program Referring to the employee assistance program is a nonpunitive approach that attempts to help the nurse as an individual and as a professional. Counseling by the staff psychiatrist may be necessary for long-term therapy but is not the initial approach. Dismissing the nurse from the job immediately is a punitive nontherapeutic response that offers no chance of rehabilitation. The client has an addiction problem; promises will not keep the client from abusing drugs.

A client who has a history of a conversion reaction that involves weakness in the right arm that periodically progresses to paralysis is hospitalized on the mental health unit of the local community hospital. While listening to instructions for a group project, the client experiences a feeling of weakness and is unable to move the right arm. After evaluating the client, what should the nurse ask? 1. "Exactly when did the weakness begin?" 2. "Is this similar to what you usually experience?" 3. "Would you like to leave the group for a while?" 4. "What emotion were you feeling before you felt the weakness?"

4. "What emotion were you feeling before you felt the weakness?" Asking what emotion the client was feeling before he felt the weakness focuses the client on the relationship between emotion and physical symptoms in a nonthreatening, accepting manner. The nurse knows when the weakness began, so it is unnecessary to ask. Asking whether this experience is similar what the client usually experiences does not identify what the person was feeling when the weakness happened. Asking the client whether he would you like to leave the group for a while will provide a secondary gain; it implies sympathy and allows the client to avoid an undesired activity.

What should a nurse consider when planning care for a client who is using ritualistic behavior? 1. The nurse must try to limit the ritualistic behavior. 2. Clients need to realize that ritualistic behavior serves no purpose. 3. The nurse should try to stop the ritual immediately after it is started. 4. Clients do not want to repeat their rituals but feel compelled to do so.

4. Clients do not want to repeat their rituals but feel compelled to do so. The repeated thought or act defends the client against even higher, more severe levels of anxiety. To deny the client the ritual may precipitate a panic level of anxiety. Usually clients who engage in ritualistic behavior recognize that the ritual serves little purpose.

A client with a history of substance abuse is brought to the emergency department. The client is having seizures, is hypertensive, and has hyperthermia. What drug should the nurse consider that the client may have been abusing? 1. Alcohol 2. Fentanyl 3. Oxycodone 4. Methamphetamine

4. Methamphetamine Methamphetamine is a stimulant that increases the heart rate and blood pressure. It can cause hyperthermia, convulsions, and death. Alcohol is a central nervous system (CNS) depressant. Overdose of alcohol leads to a decreased level of consciousness and respiratory depression. Fentanyl and oxycodone are opioid and CNS depressants. Overdose leads to hypotension, a decreased level of consciousness, and respiratory depression.

A client with the diagnosis of alcoholism explains to the nurse that alcohol has a calming effect and states, "I function better when I'm drinking than when I'm sober." What defense mechanism does the nurse identify? 1. Sublimation 2. Suppression 3. Compensation 4. Rationalization

4. Rationalization The attempt to justify a behavior by giving it acceptable motives is an example of rationalization. Sublimation is the substitution of a maladaptive behavior for a more socially acceptable behavior. Suppression is the intentional exclusion of things, people, feelings, or events from consciousness. Compensation is the attempt to emphasize a characteristic viewed as an asset to make up for a real or imagined deficiency.

A client in an acute mental health unit appears severely depressed. The client does not initiate conversations or perform personal care. Questions are answered with a barely audible one- or two-word response. The nurse sits with the client and makes no demands. On what premise is the nurse's intervention for this client based? 1. Nurses are required to spend time with assigned clients. 2. Environmental stimulation helps depressed clients feel more worthwhile. 3. Nurses are expected to initiate one-to-one interactions on an acute care unit. 4. Spending time with depressed clients demonstrates that they are worthy of attention.

4. Spending time with depressed clients demonstrates that they are worthy of attention. A severely depressed client has low self-esteem; spending time with a depressed client demonstrates that the client is important and worthy of attention. Although it is true that nurses are required to spend time with assigned clients, such interaction by itself does not directly address the needs of the client in this case. Although depressed clients do need stimulation, that alone is not the rationale for sitting with the client and making no demands. Although it is true that nurses are expected to initiate one-to-one interactions on an acute care unit, such interaction by itself does not address the needs of the client.

What is the best nursing intervention during the working phase of the therapeutic relationship with which to meet the needs of individuals who demonstrate obsessive-compulsive behavior? 1. Restricting their movements 2. Calling attention to the behavior 3. Keeping them busy to distract them 4. Supporting rituals while setting realistic limits

4. Supporting rituals while setting realistic limits Accepting obsessive-compulsive clients and their symptomatic behavior sets the foundation for the nurse-client relationship. Setting limits provides external controls and helps reduce anxiety. Supporting rituals while setting realistic limits is appropriate during the working phase, not the initial phase, of a therapeutic relationship. Restricting movements will have no effect other than to increase anxiety. Calling attention to the behavior will increase the client's anxiety and increase use of the behavior. Keeping the client busy in an effort to distract him or her is unrealistic.

What behavior by a client with a long history of alcohol abuse is an indication that the client may be ready for treatment? 1. Drinking only socially 2. Not drinking for a week 3. Hospitalization for detoxification 4. Verbalizing an honest desire for help

4. Verbalizing an honest desire for help When clients with alcohol problems voice a desire for help, it usually signifies that they are ready for treatment, because they are admitting they have a problem. Adherence to an alcohol treatment program requires abstinence. A week is too short a time to signal readiness for treatment. Hospitalization alone is not an indication that the client is really ready for treatment, because many factors can influence admission.

Some clients repeatedly perform ritualistic behaviors throughout the day to limit anxious feelings. The nurse determines that these behaviors are what? 1. Obsessions 2. Compulsions 3. Under personal control 4. Related to rebelliousness

2. Compulsions A compulsion is an uncontrollable, persistent urge to perform an act repetitively to relieve anxiety. An obsession is a persistent idea, thought, or impulse that cannot be eliminated from consciousness with logical reasoning. The urge to perform a compulsive act is not under the client's control because avoiding the act increases anxiety. Clients are compelled to perform these ritualistic behaviors; they are not trying to rebel.

A withdrawn client refuses to get out of bed and becomes upset when asked to do so. What nursing action is most therapeutic? 1. Requiring the client to get out of bed 2. Staying with the client until the client calms down 3. Giving the client the PRN antipsychotic that is prescribed 4. Leaving the client alone in bed for as long as the client wishes

2. Staying with the client until the client calms down Staying with the client until the client calms down provides support and security without rejecting the client or placing value judgments on the behavior. Eventually limits will have to be set in giving care, but staying with the client and showing acceptance are immediate nursing actions. Although giving the client the PRN antipsychotic will calm the client, it does not address the problem. Leaving the client alone in bed for as long as the client wishes ignores the problem; isolation implies punishment.

A nurse is discharging a client from the mental health unit who has been treated for major depression. Which statement is most therapeutic at this time? 1. "I'm going to miss you; we've become good friends." 2. "I know that you're going to be all right when you go home." 3. "Call the contact number we gave you if you have an emergency." 4. "This is my phone number; call and let me know how you're doing."

3. "Call the contact number we gave you if you have an emergency." Instructing the client to call the contact number that was provided in case of emergency demonstrates an understanding that the newly discharged client needs to have a support system. Clients need to feel that in a crisis there will be someone there for them. The role of the nurse is not to become a good friend but instead to help the client become a functioning being again. "I know you're going to be all right when you go home" provides false reassurance; the nurse does not know this. "This is my phone number; call and let me know how you're doing" is unprofessional and blurs the roles of nurse and client.

A depressed older client has not been eating well since her admission to the hospital. The client repeatedly states, "No one cares." What is the most appropriate response by the nurse? 1. "We all care about you; now please eat." 2. "We all care about you; you have to eat to stay alive." 3. "I care about you. What are some foods you especially like?" 4. "I care about you. Will you please eat some of this food for me?"

3. "I care about you. What are some foods you especially like?" The statement "I care about you. What are some foods you especially like?" is a direct response to the client's concern and permits some exploration of food choices. Focusing on several caretakers does little to meet the client's basic security needs. "We all care about you; you have to eat to stay alive" does not address the client's comment that no one cares. "I care about you. Will you please eat some of this food for me?" encourages dependence on the nurse; the message is "Do it for me, not because it is important for you."

A client tells the nurse, "That man on the television is talking only to me." What should the nurse document that the client is exhibiting? 1. Illusion 2. Hallucination 3. Idea of reference 4. Autistic thinking

3. Idea of reference An idea of reference, also called a delusion of reference, is a fixed, false personal belief that public events and people are connected directly to the client. An illusion is a misinterpretation of a sensory stimulus. A hallucination is a perceived experience that occurs in the absence of an actual sensory stimulus. Autistic thinking is a distortion in the thought process that is associated with schizophrenic disorders.

A nurse is conducting the Mini-Mental Status examination on an older client. What should the nurse ask the client to do when testing short-term memory? 1. Subtract serial sevens from 100 2. Copy one simple geometric figure 3. Restate three random words mentioned earlier in the exam 4. Name two common objects when the nurse points to them

3. Restate three random words mentioned earlier in the exam Restating three random words mentioned earlier in the examination is a test of the client's ability to recall from short-term memory. Subtracting serial sevens from 100 is a test of the ability to calculate and pay attention. Copying one simple geometric figure is a test of visual comprehension. Naming two common objects when the nurse points to them is a test of verbal skills to identify aphasia.

After working for a week with an adolescent with anorexia nervosa, the adolescent becomes hostile and says to the nurse, "You're just like my mother. I hate you." What concept does the client's statement reflect? 1. Insight 2. Universality 3. Transference 4. Identification

3. Transference Transference occurs when a client unconsciously assigns to the therapist feelings and attitudes originally associated with another important person in the client's life. This client's statement reflects a lack of insight. Universality is the sense that one is not alone in any situation. Identification is a defense mechanism that eases anxiety. The person takes on characteristics of someone who is viewed as admirable.

Which nursing intervention is beneficial for the client with mania? 1. Reducing salt intake 2. Increasing intake of fatty foods 3. Decreasing intake of high-fiber foods 4. Increasing intake of fresh vegetables and fruits

4. Increasing intake of fresh vegetables and fruits The nurse should encourage the client with mania to consume a well-balanced diet. This includes consumption of fresh vegetables and fruits, which are also hand-held, something that works well for the client with mania. Although lower sodium is healthy, the nurse should instruct the client taking lithium to not remove salt from the diet, because reduced intake could lead to lithium toxicity. To keep the diet healthy, the nurse should instruct the client with mania to avoid junk foods that are rich in concentrated sugars and fats. The client should also be instructed to increase, not decrease, consumption of high-fiber foods to ease or prevent constipation.

A depressed client has been receiving venlafaxine (Effexor) 25 mg three times a day by mouth. The health care provider increases the dose to 37.5 mg three times a day by mouth. The pharmacy supplies scored 25-mg tablets of Effexor. How many tablets should the nurse administer? Record your answer using one decimal place. _________ tablets

Solve the problem by using ratio and proportion. Desire 37.5 mg x tablets ------------------- = --------- Have 25 mg 1 tablet 25x = 37.5 x = 37.5 ÷ 25 x = 1.5 tablets.

A client who was forced into early retirement is found to have severe depression. The client says, "I feel useless, and I've got nothing to do." What is the best initial response by the nurse? 1. "Tell me more about feeling useless." 2. "Volunteering can help you fill your time." 3. "Your illness is adding to your current feelings." 4. "Let's talk about what you'd like to be doing right now."

1. "Tell me more about feeling useless." An open-ended response encourages further discussion and allows exploration of feelings. Telling the client that volunteering will help pass the time ignores the client's feelings. The depression is not adding to the feelings; the feelings are causing the depression. Asking the client to talk about what the client would rather be doing ignores the client's feelings.

A nurse is caring for a client with generalized anxiety disorder. Which factor should be evaluated to determine the client's present status? 1. Memory 2. Behavior 3. Judgment 4. Responsiveness

2. Behavior The client's current behavior is the best indicator of the client's current level of function; all behavior has meaning. Memory, judgment, and responsiveness are all important and should be evaluated, but none is the best indicator of the client's current level of function.

A client is lonely and extremely depressed, and the health care provider prescribes a tricyclic antidepressant. The client asks the nurse what the medication will do. What is the best response by the nurse? 1. "This drug will help you forget why you're lonely and depressed." 2. "The medication will increase your appetite and make you feel better." 3. "You'll start to feel much better after taking this medication for 2 or 3 days." 4. "You'll feel less depressed when you take this with the monoamine oxidase inhibitor."

2. "The medication will increase your appetite and make you feel better." Tricyclic antidepressants create a general sense of well-being, increase appetite, and help lift depression. The client might not know the reason for depression, and the drug does not cause amnesia. Symptomatic relief usually begins after 2 to 3 weeks of therapy. Concomitant use of monoamine oxidase inhibitors and tricyclic antidepressants is contraindicated.

A nurse is caring for a client with the diagnosis of schizophrenia, paranoid type. How should the nurse plan for the client's initial care? 1. By discussing important life events 2. By providing a nonthreatening environment 3. By concentrating on the content of delusions 4. By limiting topics for discussion to recent situations

2. By providing a nonthreatening environment These clients are hypersensitive to external stimuli and respond with less anxiety to a minimally threatening environment. Discussing prominent life events is too threatening an approach and interferes with the goals of therapy. Focusing on delusional material will reinforce the delusional system. Limiting topics for discussion to recent situations is not therapeutic; it may trigger suspiciousness and hostile outbursts.

A male client with a diagnosis of antisocial personality disorder is admitted to the mental health hospital. What is the priority nursing intervention? 1. Encouraging interactions with others 2. Presenting a united, consistent staff approach 3. Assuming a nurturing, forgiving tone in disputes 4. Using seclusion when manipulative behaviors are exhibited

2. Presenting a united, consistent staff approach Clients with an antisocial personality disorder need a consistent, united staff approach because they are experts in manipulation and exploitation; they may ignore rules and divide staff members. These clients do not need to be encouraged to interact with other people because they are forward in their approach to others. A nurturing, forgiving tone will foster and worsen manipulation, not decrease it. Seclusion is an overreaction to manipulative behaviors; it implies punishment, which is not productive. Seclusion is used only when the client may injure himself or others.

A client with the diagnosis of manic episode of bipolar disorder attends a mental health day treatment program. What supervised activity will be most therapeutic for this client during the early phase of treatment? 1. Doing a needlepoint project 2. Joining a brief swimming competition 3. Walking around the facility with a nurse 4. Playing a board game with another client

3. Walking around the facility with a nurse Walking around the facility with a nurse does not involve an element of competition and still allows the client to channel excess energy safely. A needlepoint project requires fine motor skills of a client who is hyperactive and whose attention span is limited. The sense of competition and added stimulation provided by a swimming competition may increase the client's anxiety. The client is too hyperactive to play a board game and may respond with distractibility or aggressiveness toward others.

A woman with bipolar disorder, manic episode, has been spending thousands of dollars on clothing and makeup. She has been partying in bars every night and rarely sleeps or eats. The nurse in the outpatient clinic, knowing that this client rarely eats, recognizes that her eating problems most likely result from what? 1. Feelings of guilt 2. Need to control others 3. Desire for punishment 4. Excessive physical activity

During a manic episode, hyperactivity and the inability to sit still long enough to eat are the causes of eating difficulties. Feelings of guilt do not precipitate eating difficulties in clients with the diagnosis of bipolar disorder, manic episode. Clients in a manic episode of bipolar disorder have a need to avoid and therefore control anxiety associated with depression; they do not have a need to control others. Clients in a manic episode of bipolar disorder have a need to avoid and therefore control anxiety associated with depression; they do not have a desire for punishment.

An antidepressant is prescribed for a depressed older client. After 1 week the client's son expresses concern that there does not seem to be much improvement. How should the nurse respond? 1. "Antidepressant therapy requires several weeks before it becomes effective." 2. "Antidepressant therapy will be more effective as the physical condition improves." 3. "Additional medications may be required before behavioral changes will be observed." 4. "Additional time is needed for the medication to become effective because of the prolonged depression."

1. "Antidepressant therapy requires several weeks before it becomes effective." The effects of antidepressants are cumulative; it may take 3 to 4 weeks before improvement is identified. Antidepressants do not become more effective as a client's physical condition improves. Antidepressants become effective after 3 or 4 weeks, regardless of the duration of the depression.

What is the priority nursing intervention in the planning of nursing care for an adolescent client with anorexia nervosa? 1. Rewarding weight gain by increasing privileges 2. Discussing the importance of eating a balanced diet 3. Encouraging the client to include high-calorie foods in the diet 4. Family therapy focusing on the influence of the client's behavior on the family

1. Rewarding weight gain by increasing privileges Behavior modification programs are helpful treatment modes for many clients with anorexia nervosa. Discussing the importance of eating a balanced diet is ineffective. The person with anorexia nervosa is more concerned with losing weight than with eating a balanced diet. A well-balanced diet should be encouraged, but actual weight gain is critical and must be reinforced. Although family therapy may be helpful, emphasis on the anorexia may reinforce the negative behavior. Also, family therapy will not be a priority until the client gains weight.

A nurse encourages a client to join a self-help group after being discharged from a mental health facility. What is the purpose of having people work in a group? 1. Support 2. Confrontation 3. Psychotherapy 4. Self-awareness

1. Support Members of a self-help group share similar experiences and can provide valuable understanding and support to one other. Although confrontation and self-awareness may occur, these are not the primary purposes of self-help groups. Self-help groups provide an opportunity for people to interact, not to engage in professional psychotherapy.

A client with the diagnosis of an antisocial personality disorder responds to limit-setting by a nurse by saying, "You sure do look messy today." What is the most appropriate response by the nurse? 1. "Don't you feel well today?" 2. "I get the feeling you're angry with me." 3. "I really didn't think anyone would notice." 4. "Do you think that was a nice thing to say to me?"

2. "I get the feeling you're angry with me." The response "I get the feeling you're angry with me" helps the client focus on feelings rather than emphasizing the current unacceptable behavior. The response "Don't you feel well today?" gives the client an alibi for unacceptable behavior. By saying "I really didn't think anyone would notice," the nurse is becoming defensive rather than dealing with the problem directly. The response "Do you think that was a nice thing to say to me?" points out the behavior in a negative way.

A nurse is counseling a client who abuses cocaine. The nurse recognizes that this drug is representative of which drug category? 1. An opioid 2. A stimulant 3. A barbiturate 4. A hallucinogen

2. A stimulant Cocaine is classified as a stimulant. It is inhaled in its powdered form or smoked as crack; its use creates experiences similar to but more intense than those experienced with the amphetamines, and its withdrawal results in a deeper crash. Opioids and barbiturates are central nervous system depressants. Hallucinogens produce cerebral excitation that can yield a state similar to psychosis.

A client on treatment for depression visited the primary healthcare provider with a complaint of blurred vision and constipation. Which drugs are responsible for these adverse effects? Select all that apply. 1. Phenelzine 2. Amoxapine 3. Maprotiline 4. Desipramine 5. Amitriptyline

2. Amoxapine 4. Desipramine 5. Amitriptyline Amoxapine, desipramine, and amitriptyline are first-generation antidepressants drugs with potential adverse effects of blurred vision and constipation. Phenelzine is a monoamine oxidase inhibitor. Dizziness and dyskinesias are the adverse effects of this drug. Maprotiline is a second-generation antidepressant drug with potential adverse effects of drowsiness and abnormal dreams.

Which often-abused medication is not hallucinogenic? 1. Ketamine 2. Barbiturates 3. Phencyclidine 4. Lysergic acid diethylamide

2. Barbiturates Barbiturates are one of the most often abused sedative-hypnotic medications, but they are not hallucinogens. Ketamine, phencyclidine, and lysergic acid diethylamide are hallucinogens.

After an automobile collision involving a fatality and a subsequent arrest for speeding, a client has amnesia regarding the events surrounding the accident. Which defense mechanism is being used by the client? 1. Projection 2. Repression 3. Suppression 4. Rationalization

2. Repression Repression is coping with overwhelming emotions by blocking awareness or memory of the stressful event. Projection is attributing one's own unacceptable feelings and thoughts to others. Suppression is consciously keeping unacceptable feelings and thoughts out of awareness. Rationalization is the attempt to mask unacceptable feelings or behaviors by providing excuses and explanations.

Which condition is a physical condition in an alcoholic client? 1. Social isolation 2. Risk for poisoning 3. Ineffective impulse control 4. Risk for compromised human dignity

2. Risk for poisoning Risk for poisoning is a physical condition that may be exhibited in an alcoholic client. Social isolation, ineffective impulse control, and risk for compromised human dignity are psychosocial conditions that may be exhibited in alcoholic clients.

A 44-year-old client has been unable to function since her husband asked for a divorce 2 weeks ago. She is brought to the crisis intervention center by a friend. What type of crisis is this situation? 1. Social 2. Situational 3. Maturational 4. Developmental

2. Situational Situational crises involve an unanticipated loss, such as a divorce, that is threatening to the client. Social crises involve multiple losses such as those occurring during major disasters. Maturational crises occur in response to stress experienced as one struggles with developmental tasks. Developmental (maturational) crises are associated with developmental tasks; divorce is not a developmental task.

A client with newly diagnosed multiple myeloma asks, "How long do you think I have to live?" What is the most appropriate response by the nurse? 1. "Let me ask your primary healthcare provider for you." 2. "I can understand why you are worried." 3. "Tell me about your concerns right now." 4. "It depends on whether the tumor has spread."

3. "Tell me about your concerns right now." The response "Tell me about your concerns right now" encourages the client to review facts and provides an opportunity to talk about feelings. The response "Let me ask your primary healthcare provider for you" suggests the nurse does not want to discuss the subject; it abdicates the nurse's responsibility to explore the issue with the client. Although it is an empathic answer, the response "I can understand why you are worried" does not encourage the client to explore feelings; it may increase anxiety. Although the statement "It depends on whether the tumor has spread" is true, the response does not encourage the client to examine feelings.

A client tells the nurse, "I'm a terrible, evil person. The voices are telling me that God needs to punish me." What is the most therapeutic initial response by the nurse? 1. "God is loving and won't punish you." 2. "Those voices you're hearing are a fantasy." 3. "Tell me what you're thinking about yourself." 4. "You aren't wicked, both God and I love you."

3. "Tell me what you're thinking about yourself." Encouraging the client to focus on the self will facilitate communication and foster self-perception. Stating that God will not punish the client denies the client's feelings and provides false reassurance. Stating that the voices are fantasy denies the client's experience. Stating that the client is not wicked denies the client's feelings and provides false reassurance.

A nurse on the psychiatric unit of the hospital has been assigned four clients for the shift. The assignment includes an 84-year-old client who is severely depressed, a 73-year-old client who is being discharged, a 53-year-old client who was admitted for lithium toxicity, and a 48-year-old client who has panic attacks. Which client should the nurse evaluate first after receiving report? 1. 84-year-old client 2. 73-year-old client 3. 53-year-old client 4. 48-year-old client

3. 53-year-old client The 53-year-old client should be evaluated first because of the severity of adaptations associated with lithium toxicity. A severely depressed client has a low energy level and is not at the greatest risk at this time. A client who is stable enough to be discharged does not need immediate attention. Clients with panic attacks usually seek immediate attention when it is needed.

A nurse is caring for a client with a diagnosis of catatonic schizophrenia. What clinical finding does the nurse expect the client to exhibit? 1. Crying 2. Self-mutilation 3. Immobile posturing 4. Repetitive activities

3. Immobile posturing Clients with catatonic schizophrenia exhibit rigidity and posturing behaviors. Most clients with catatonic schizophrenia are unable to express feelings and would be unlikely to cry. Self-mutilation is associated with depression. Repetitive activities are associated with obsessive-compulsive disorders.

A nurse is administering medications to clients on a psychiatric unit. What does the nurse identify as the reason that so many psychiatric clients are given the drug benztropine or trihexyphenidyl in conjunction with the phenothiazine-derivative neuroleptic medications? 1. They reduce postural hypotension. 2. They potentiate the effects of the neuroleptic drug. 3. They combat the extrapyramidal side effects of the neuroleptic drug. 4. They ameliorate the depression that may accompany schizophrenia.

3. They combat the extrapyramidal side effects of the neuroleptic drug. Benztropine and trihexyphenidyl control the extrapyramidal (parkinsonian) manifestations associated with the neuroleptics and are classified as antiparkinsonian drugs. These drugs do not reduce postural hypotension, nor do they potentiate phenothiazine derivatives or have an effect on depression.

A nurse has been assigned to work with a depressed client on a one-on-one basis. The next morning the client refuses to get out of bed, saying, "I'm too sick to be helped, and I don't want to be bothered." What is the best response by the nurse? 1. "You won't feel better unless you make the effort to get up and get dressed." 2. "I know you'll feel better again if you just make an attempt to help yourself." 3. "Everyone feels this way in the beginning as they confront their feelings. I'll sit with you." 4. "I know you don't feel like getting up, but you might feel better if you did. Let me help you get started."

4. "I know you don't feel like getting up, but you might feel better if you did. Let me help you get started." The statement "I know you don't feel like getting up, but you might feel better if you did. Let me help you get started" acknowledges the client's feelings, offers hope, and helps the client to a higher level of function. The statement "You won't feel better unless you make the effort to get up and get dressed" ignores the client's feelings and may not be true. The statement "I know you'll feel better again if you just make an attempt to help yourself" denies the client's feelings, and feeling better cannot be guaranteed. The statement "Everyone feels this way in the beginning as they confront their feelings. I'll sit with you" minimizes the client's feelings; also the client is not interested in how others feel.

A client who has been attending a day treatment facility for 1 month with the diagnosis of major depression is to be discharged in a week. Because the nurse and the client are aware of this, what is the most appropriate comment by the nurse? 1. "We have just a few sessions left. I'm really pleased at your progress." 2. "Your discharge date has been set for next week. That's wonderful news." 3. "We have five sessions remaining. We need to start making plans to end our sessions." 4. "I understand that your discharge is set for next week. I'm wondering how you feel about that."

4. "I understand that your discharge is set for next week. I'm wondering how you feel about that." Plans for termination that take emotional needs into account are best made after exploration of the client's thoughts and feelings about discharge. Noting that there are just a few sessions left and expressing pleasure at the client's progress acknowledges the future termination but focuses on the nurse's, not the client's, feelings. Noting that the client's discharge date has been set for next week and calling this wonderful news acknowledges the future termination but suggests that the client should feel wonderful about the discharge, which may or may not be true. Although noting that the client and nurse have five sessions remaining and that the two need to start making plans to end the sessions acknowledges the future termination, plans for termination should be made after a discussion of the client's emotional response to the pending discharge.

The nurse observes biting, rocking, sucking, and lags in intellectual development in a child. She also concludes the child is suffering from sleep disorders. What could be the reason for the child's condition? 1. Physical neglect 2. Sexual abuse 3. Physical abuse 4. Emotional abuse

4. Emotional abuse The child may be neglected if the parent is having a mental illness such as psychosis. Sleep disorders, feeding disorders, biting, rocking, sucking, and lags in intellectual development are behavioral findings associated with emotional abuse. Physical neglect, sexual abuse, and physical abuse manifest in different sets of signs and symptoms.

An adolescent client with an antisocial personality disorder has been admitted to the hospital because of drug abuse and repeated sexual acting-out behavior. Which client behavior supports the nurse's conclusion that actions directed toward modifying the behavior of this client have been successful? 1. Promises never to take drugs again 2. Discusses the need to seduce other adolescents 3. Recognizes the need to conform to society's norms 4. Identifies the feelings underlying the acting-out behavior

4. Identifies the feelings underlying the acting-out behavior Identifying the feelings underlying the acting-out behavior demonstrates the development of some insight and a willingness to begin looking at the underlying causes of behavior. A promise to never take drugs will probably have little meaning to the client. Discussing the need to seduce other adolescents reflects a continuation of the client's behavior before being hospitalized. Agreeing to conform to society's norms is not sufficient motivation for lasting change.

A nurse is caring for a client with an obsessive-compulsive personality disorder that involves rituals. What should the nurse conclude about the ritual? 1. It has a purpose but is useless. 2. It is performed after long urging. 3. It appears to be performed willingly. 4. It seems illogical but is needed by the person.

4. It seems illogical but is needed by the person. The client's exact adherence to the compulsive ritual relieves anxiety, at least temporarily. Furthermore, it meets a need and is necessary to the client. The compulsive act is purposeless repetition and useful only in that it temporarily eases the client's anxiety. Urging has no effect getting the client to start or stop the ritualistic behavior. The person cannot stop the activity; it is not under his or her voluntary control.

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? 1. Akathisia 2. Torticollis 3. Tardive dyskinesia 4. Parkinsonian syndrome

Akathisia, a side effect of haloperidol (Haldol), develops early in therapy and is characterized by restlessness and agitation. Torticollis is characterized by a stiff neck (wry neck). Tardive dyskinesia is characterized by gross involuntary movements of the extremities, tongue, and facial muscles that develop after prolonged therapy. Pseudoparkinsonism is characterized by motor retardation, rigidity, and tremors; the reaction resembles Parkinson's syndrome but usually responds to decreasing the dose, the administration of an antidyskinetic medication, or discontinuation of the haloperidol.

A client who has been taking the prescribed dose of zolpidem for 5 days returns to the clinic for a follow-up visit. When interviewing the client, the nurse identifies that the medication has been effective when the client makes which statement? 1. "I have less pain." 2. "I have been sleeping better." 3. "My blood glucose is under control." 4. "My blood pressure is coming down."

2. "I have been sleeping better." Zolpidem is a sedative-hypnotic that produces central nervous system depression in the limbic, thalamic, and hypothalamic areas of the brain. Zolpidem is not an analgesic, antidiabetic, or antihypertensive medication.

A male client with the diagnosis of a bipolar disorder, depressed episode, is found lying on the floor in his room in the psychiatric unit. He states, "I don't deserve a comfortable bed; give it to someone else." What is the best response response by the nurse? 1. "Everyone has a bed. This one is yours." 2. "You are not allowed to sleep on the floor." 3. "I don't understand why you're on the floor." 4. "You're a valuable person. You don't need to lie on the floor."

1. "Everyone has a bed. This one is yours." A matter-of-fact approach helps avoid a cycle in which the nurse expresses concern to a client who feels unworthy, which increases feelings of unworthiness. Citing a hospital policy focuses on rules and regulations, which may exacerbate the client's negative personal feelings because he is breaking the rules. "I don't understand why you're on the floor" is a statement that the client may not be able to respond to. Telling the client that he is a valuable person and doesn't need to lie on the floor may increase feelings of unworthiness because it creates a gap between the nurse's estimate of the client and what the client feels.

The nurse finds a client with schizophrenia lying under a bench in the hall. The client says, "God told me to lie here." What is the best response by the nurse? 1. "I didn't hear anyone talking; come with me to your room." 2. "What you heard was in your head; it was your imagination." 3. "Come to the dayroom and watch television; you'll feel better." 4. "God wouldn't tell you to lie there in the hall. God wants you to behave reasonably."

1. "I didn't hear anyone talking; come with me to your room." By saying "I didn't hear anyone talking; come with me to your room," the nurse is focusing on reality and trying to distract and refocus the client's attention. "What you heard was in your head; it was your imagination" is too blunt and belittling; this approach rarely is effective. "Come to the dayroom and watch television; you'll feel better" is false reassurance; the nurse does not know that the client will feel better. "God wouldn't tell you to lie in the hall; God wants you to behave reasonably" may be interpreted as belittling or an attempt to convince the client that the behavior is irrational, which is usually ineffective.

A client experiencing hallucinations tells a nurse, "The voices are telling me I'm no good." The client asks whether the nurse hears the voices. What is the most appropriate response by the nurse? 1. "I don't hear the voices, but I believe that you can hear them." 2 "It is the voice of your conscience, and only you can control that." 3 "Those voices are coming from within you; only you can hear them." 4. "The voices are a symptom of your illness; don't pay attention to them."

1. "I don't hear the voices, but I believe that you can hear them." The nurse, demonstrating knowledge and understanding, accepts the client's perceptions even though they are hallucinatory. "It is the voice of your conscience, and only you can control that," may increase the client's guilt and fear. "Those voices are coming from within you; only you can hear them," may increase the client's fear. "The voices are a symptom of your illness; don't pay attention to them," presents reality but negates the client's feelings and asks for an unrealistic response.

The parent of a child with a tentative diagnosis of attention deficit hyperactivity disorder (ADHD) arrives at the pediatric clinic insisting on getting a prescription for medication that will control the child's behavior. What is best response by the nurse? 1. "It must be frustrating to deal with your child's behavior." 2. "Have you considered any alternatives to using medication?" 3. "Perhaps you're looking for an easy solution to the problem." 4. "Let me teach you about the side effects of medications used for ADHD."

1. "It must be frustrating to deal with your child's behavior." Stating that it must be frustrating acknowledges the parent's distress and encourages verbalization of feelings. Asking whether any alternatives have been considered is insensitive to the parent's feelings; it may be more appropriate later, when the parent's stress has diminished. Although the parent may be looking for an easy answer to the problem, this response is confrontational and may close off communication. Asking to teach the parent about the side effects of ADHD medications is insensitive to the parent's feelings; it may be more appropriate later if medication is prescribed and health teaching is started.

A client with schizophrenia plans an activity schedule with the help of the treatment team. A written copy is posted in the client's room. What should the nurse say when it is time for the client to go for a walk? 1. "It's time for you to go for a walk now." 2. "Do you want to take your scheduled walk now?" 3. "When would you like to go for your walk today?" 4. "You're supposed to be going for your walk now."

1. "It's time for you to go for a walk now." Telling the client that it is time to take a walk is concise and does not require decision making; it is therefore less likely to increase anxiety. "Do you want to take your scheduled walk now?" asks the client to make a decision when a refusal is unacceptable. Asking "When would you like to go for your walk today?" requires the client to make a decision, which when the client is acutely ill may increase anxiety; also, it permits the unacceptable answer of "never." "You're supposed to be going for your walk now" is somewhat accusatory; it may increase anxiety by placing responsibility on the client.

During a routine yearly physical an older adult says to a nurse, "I haven't had sex lately because I can't get an erection anymore." What should the nurse's initial response be? 1. "Let's discuss this concern a little more." 2. "Be sure to tell your doctor about this problem." 3. "There is medication available for erectile dysfunction." 4. "This is an expected physiological response to getting older."

1. "Let's discuss this concern a little more." "Let's discuss this concern a little more" communicates to the client that the nurse is willing and able to explore this concern. It is an open-ended statement that allows the client to control the direction of the conversation. By saying, "Be sure to tell your doctor about this problem" the nurse abdicates responsibility to the health care provider. The nurse is capable of and legally responsible for collecting information and exploring the client's feelings and concerns. The response "There is medication available for erectile dysfunction" is premature; it moves immediately to a solution before adequate information has been collected. Also, the term erectile dysfunction is related to a medical diagnosis and its use at this time may increase client anxiety. Although sexual function diminishes as men age, many other factors (e.g., physiological problems, interpersonal conflicts, emotional stress) also influence sexual function.

Encouragement and appropriate praise should be given to clients who are hyperactive to help them increase their feelings of self-esteem. When they have acted appropriately, what is the best statement for the nurse to make in an effort to let them know of their improvement? 1. "You behaved well today." 2. "I knew you could behave." 3. "Everyone likes you better when you behave like this." 4. "Your behavior today was much better than it was yesterday."

1. "You behaved well today." "You behaved well today" simply states a fact and delivers praise without making demands. "I knew you could behave" puts the total responsibility for control on a client who needs to have external controls set. "Everyone likes you better when you behave like this" does not help the client separate the self from the behavior; it tells the client that acting-out behavior will result in rejection. The client may not recall what happened yesterday and may not know why today's behavior is better.

A nurse enters a depressed client's room on the evening of admission and observes the client sitting in a chair crying. What is the most therapeutic response by the nurse? 1. "You're crying. Let's talk about it." 2. "Let me get a cup of coffee; then we can talk." 3. "Visitors will be here soon; you'd better get ready." 4. "You'll feel better soon. Come to the sitting room with me."

1. "You're crying. Let's talk about it." Noting that the client is crying and suggesting that the nurse and client talk about it addresses the behavior observed, and the offer by the nurse to spend time to help the client implies that the client is worthy. With "Let me get a cup of coffee; then we can talk" the nurse offers to help but places the client second by stating the desire to get coffee first. The nurse denies the client's feelings by focusing on getting ready for visitors. Assuring the client that she will feel better soon and asking her to come to the sitting room constitutes false reassurance. The nurse first recognizes the client's feelings and then moves away from discussing them.

One evening a nurse finds a client who has been experiencing persecutory delusions trying to get out the door. The client begs, "Please let me go. I trust you. The Mafia is going to kill me tonight." Which response is most therapeutic? 1. "You're frightened. Come with me to your room, and we can talk about it." 2. "Come with me to your room. I'll lock the door and no one will get in to harm you." 3. "Nobody here wants to harm you, and you know that. I'll come with you to your room." 4. "Thank you for trusting me. Maybe you can trust me when I tell you that no one will kill you here."

1. "You're frightened. Come with me to your room, and we can talk about it." Acknowledging that the client is frightened and offering a chance to talk acknowledges the client's feelings and provides assurance that the staff member will be present. Locking the client in a room will only increase the fear and worsen the delusion. The client does not know that no one wants to harm him; if the client did, the delusion would not be present. The client is not ready to accept that no one wants to kill him or her and really believes that danger is imminent.

A client describes his delusions in minute detail to the nurse. How should the nurse respond? 1. By changing the topic to reality-based events 2. By continuing to discuss the delusion with the client 3. By getting the client involved in a social project with peers 4. By disputing the perceptions with the use of logical thinking

1. By changing the topic to reality-based events Decreasing time spent on delusions prevents reinforcement of psychotic thinking. Discussing reality-based events improves contact with reality. Challenging the client may increase anxiety. The client will have difficulty getting involved in a social activity; the activity will not stop the delusion. Encouraging discussion will give validity to the delusion.

A nurse is caring for a client with the diagnosis of somatoform disorder, conversion type. What type of affect does the nurse expect this client to exhibit? Select all that apply. 1. Calm 2. Cheerful 3. Depressed 4. Frightened 5. Matter-of-fact

1. Calm 5. Matter-of-fact The symptoms prevent the individual from being forced to act in relation to a conflict or stressor; the client's symptoms thus reduce anxiety and remove the conflict. The individual demonstrates a lack of concern about the symptoms (la belle indifférence). The individual will not be happy and cheerful, sad and depressed, or frightened.

A female client is admitted to the hospital after attempting suicide. She reveals that her desire for sex has diminished since her child's birth 3 years ago. What is most directly related to the client's loss of interest in sex? 1. Depression 2. Dependency 3. Marital stress 4. Identity confusion

1. Depression Decreased sexual desire is a major symptom of clinical depression. Other vegetative signs of depression include changes in bowel elimination, eating habits, and sleeping patterns. Although depression is often related to unmet dependency needs, the decreased sexual desire is associated with the depression, not the unmet dependency needs. The sexual difficulties are associated with the depression, and the depression, not the sexual difficulties, may be the major cause of marital stress. Also, there are no data indicating marital stress. Role confusion, not identity confusion, is usually associated with depression.

When a client is expressing severe anxiety by sobbing in the fetal position on her bed, what is the nurse's priority? 1. Ensuring a safe therapeutic milieu 2. Monitoring and documenting vital signs 3. Eliminating the cause of the client's anxiety 4. Ensuring that the client's physical needs are met

1. Ensuring a safe therapeutic milieu Client safety is the nurse's first priority, and because the client has not experienced any physical injuries and is not at risk, attention should be directed toward psychiatric risk, in this case crisis control. The severely stressed individual is likely to experience increased vital signs and will continue to have physiological needs such as food and water; however, these issues do not take the priority over a psychiatric crisis. The client will not be able to concentrate on therapy related to identifying the source of the anxiety until the crisis has been managed.

A client with agoraphobia becomes increasingly anxious, often panics, and can no longer leave the house. The client is admitted to the psychiatric unit of the local hospital. What is a realistic short-term nursing objective for this client? 1. Feeling safe in the unit 2. Increasing self-esteem 3. Going out unaccompanied 4. Feeling comfortable in groups

1. Feeling safe in the unit A calm, quiet, nonthreatening, supportive environment eases anxiety and decreases the need to use maladaptive coping techniques such as phobias. Increased self-esteem is a long-term objective because low self-esteem is basic to the development of phobias. Going out unaccompanied and feeling comfortable in groups are long-term objectives; at this time they will only increase anxiety.

A client with a history of schizophrenia attends the mental health clinic for a regularly scheduled group therapy session. The client arrives agitated and exhibits behaviors that indicates that she is hearing voices. When a nurse begins to walk toward her, the client pulls out a large knife. What is the best approach by the nurse? 1. Firm 2. Passive 3. Empathetic 4. Confrontational

1. Firm A firm approach prevents anxiety transference and provides structure and control for a client who is out of control. A passive approach for a client who may be out of control does not provide structure, which may increase the client's anxiety. Although the nurse should always base a therapeutic response on empathy, an obviously empathetic response may indicate to the client that the behavior is acceptable. A confrontational approach in this situation may escalate the client's agitation and precipitate further acting out.

During an interview of a client with a diagnosis of bipolar I disorder, manic episode, the nurse expects the client to demonstrate what? 1. Flight of ideas 2. Ritualistic behaviors 3. Associative looseness 4. Auditory hallucinations

1. Flight of ideas Flight of ideas is a fragmented, pressured, nonsequential pattern of speech typically used during a manic episode. Ritualistic behaviors are repetitive, purposeful, and intentional behaviors that are carried out in a stereotyped fashion; they are found in clients with obsessive-compulsive disorders. Associative looseness is the pattern of speech found in clients with schizophrenia; usual connections between words and phrases are lost to the listener and meaningful only to the speaker. Hallucinations are false perceptions generated by internal stimuli; they are found in clients with the diagnosis of schizophrenia.

A client who was involved in a near-fatal automobile collision arrives at the mental health clinic with complaints of insomnia, anxiety, and flashbacks. The nurse determines that the client is experiencing symptoms of crisis. What is the nurse's initial intervention? 1. Focusing on the present 2. Identifying past stressors 3. Discussing a referral for psychotherapy 4. Exploring the client's history of mental health problems

1. Focusing on the present Crisis intervention deals with the here and now; the past is not important except in building on client strengths. The client is anxious and uncomfortable because of the current situation; the focus is on the present, not the past. Psychotherapy is not appropriate for crisis intervention; psychotherapy focuses on the causes of current feelings and behavior and may be provided long term. Exploring the client's history of mental health problems is not significant to crisis intervention.

What should the nurse do to achieve a primary objective of providing a therapeutic daycare environment for a client who is withdrawn and reclusive? 1. Foster a trusting relationship 2. Administer medications on time 3. Involve the client in a group with peers 4. Remove the client from the family home

1. Foster a trusting relationship An interpersonal relationship based on trust must be established before a client can be helped. Administering medications on time is an important part of the treatment and care, but it is of lesser importance than a trusting relationship. Socialization comes at a later point in therapy. There is nothing to indicate a need to remove the client from the home.

A nurse observes a client with developmental delays eating soft food without utensils. What is the best nursing intervention? 1. Giving the client a spoon and suggest that it be used 2. Saying jokingly, "Well, I guess fingers were made before forks." 3. Ignoring the behavior and observing several additional meals before intervening 4. Removing the food while saying, "You can't have any more until you use your spoon."

1. Giving the client a spoon and suggest that it be used The client needs limits to be set. This response sets limits and rejects the behavior but accepts the client. Joking does not help raise the client to a higher level of function. Ignoring the behavior and observing several additional meals before intervening serves no useful purpose; inappropriate behavior should be addressed when it is first noted. Refusing the client more food until the spoon is used is a punishing action; it shows no support or acceptance of the client.

A child has been hospitalized repeatedly for illnesses of unknown origin. Finally the health care provider makes the diagnosis of Munchausen syndrome by proxy. What is the most therapeutic approach by the nurse to the involved parent? 1. Confrontation 2. Open communication 3. Health teaching about child-rearing 4. Validation of the child's physical status

2. Open communication Maintaining open communication is important for any therapeutic nurse-client relationship. Confrontation will put the parent on the defensive and close off communication. Health teaching at this time is premature; the parent is not ready for this approach. Validation of the child's physical status focuses on the physical symptoms, which will reinforce the parent's behavior.

An older client with the diagnosis of dementia of the Alzheimer type is admitted to a long-term care facility. When planning care for this client, the nurse recalls what about confusion? 1. It occurs with a transfer to new surroundings 2. It will be unchanged despite reality orientation 3. It is a common finding and is expected with aging 4. It results from brain changes that make interventions futile

1. It occurs with a transfer to new surroundings A change in environment and introduction of unfamiliar stimuli precipitate confusion in clients with dementia-type disorders; with appropriate intervention, including frequent reorientation, confusion can be reduced. Reality orientation can reduce confusion when these clients are confronted with unfamiliar surroundings. The assertions that reality orientation is ineffective, that confusion is an expected finding in aging, and that brain changes in dementia make interventions futile are all untrue.

Clients addicted to alcohol often use the defense mechanism of denial. What is the reason that this defense is so often used? 1. It reduces their feelings of guilt. 2. It creates the appearance of independence. 3. It helps them live up to others' expectations. 4. It makes them look better in the eyes of others.

1. It reduces their feelings of guilt. Alcoholic clients often use denial as a defense against feelings of guilt; this reduces anxiety and protects the self. Denial may make a client seem more stable to others, not independent. Denial deals more with a client's own expectations. Looking better in the eyes of others may be part of the reason, but the bigger motivating factor is to ease guilt feelings.

A client is found to have an adjustment disorder with mixed anxiety and depression. What should the nurse anticipate as the client's primary problem? 1. Low self-esteem 2. Deficient memory 3. Intolerance of activity 4. Disturbed personal identity

1. Low self-esteem When a client has an adjustment disorder, anxiety may be related to a disturbance in self-esteem and depression may be related to impaired social interaction. Problems with memory are not specifically related to an adjustment disorder. Activity intolerance, which is related to oxygenation problems, is not associated with adjustment disorders. A client with an adjustment disorder does not experience a disturbance in personal identity.

Which affective disorder involves a persistent overactive and euphoric state? 1. Mania 2. Cyclothymic disorder 3. Postpartum depression 4. Seasonal affective disorder

1. Mania A client suffering from mania will experience episodes of excessive energy and euphoria that have the potential to accelerate and intensify. Cyclothymic disorder is a pattern that involves repeated mood swings between hypomania, which is milder than manic episodes, and depression. Postpartum depression and seasonal affective disorder are connected with hormonal imbalances, but the mood is not characterized by manic episodes of energy and euphoria.

A nurse is planning care for a client admitted to the unit with a diagnosis of bipolar disorder, manic phase. In which type of room should the nurse tell the admissions clerk to place this client? 1. Private 2. Isolation 3. Semi-private 4. Negative-airflow

1. Private The client who is manic needs a nonstimulating environment. A person who is bipolar is not contagious and does not require an isolation room. The presence of another person in the room is considered stimulating and may interfere with the rest and sleep of both clients. A client who is bipolar does not need a negative-airflow room. This type of room is appropriate for a client with a communicable disease, such as tuberculosis, that requires airborne precautions.

A depressed client often sleeps past the expected time of awakening and throughout the day spends excessive time resting and sleeping. Which nursing intervention is appropriate for this client? 1. Restricting the client's access to the bedroom 2. Offering the client a series of relaxation tapes 3. Rescheduling the client's bedtime to an earlier hour 4. Suggesting that the client exercise before going to bed

1. Restricting the client's access to the bedroom The goal is 6 to 8 hours of rest at night; too much time spent sleeping in the daytime will defeat the goal of adequate rest at night. Offering the client a series of relaxation tapes will contribute to the client's desire for relaxation and sleep. Rescheduling the client's bedtime to an earlier hour will support the client's hypersomnia; the client already sleeps too much. Suggesting that the client exercise before going to bed will increase the metabolic rate, which is not conducive to rest.

A 17-year-old client is admitted to the hospital because of weight loss and malnutrition, and the health care provider diagnoses anorexia nervosa. After the client's physical condition is stabilized, the provider, in conjunction with the client and parents, decides to institute a behavior-modification program. What component of behavior modification verbalized by one of the parents leads the nurse to conclude that the parent has an understanding of the therapy? 1. Rewarding positive behavior 2. Deconditioning fear of weight gain 3. Decreasing unnecessary restrictions 4. Reducing anxiety-producing situations

1. Rewarding positive behavior In behavior modification, positive behavior is reinforced, and negative behavior is punished or not reinforced. Deconditioning the client's fears, decreasing the number of unnecessary restrictions, and reducing the number of anxiety-causing situations may each be a part of the program, but none is a major component.

What characteristic of an environment should the nurse consider important for a confused older adult with socially aggressive behavior? 1. Sets limits 2. Has variety 3. Is group oriented 4. Allows freedom of expression

1. Sets limits Having poor control, these individuals cannot set limits for themselves and require an environment in which appropriate limits for behavior are set for them. Variety will increase anxiety. The daily routine should be structured and repetitive. A group-oriented environment is too stimulating for a person with socially aggressive behavior. Freedom of expression may result in injury to the client or others because the client may be unable to control impulses.

A teenager with anorexia nervosa is admitted to the adolescent unit of a mental health facility and signs a contract calling for her to gain weight or lose privileges. There is no weight gain after a week. What should the nurse explain to the client? 1. The prearranged consequences will go into effect. 2. Death from starvation could occur if the client does not eat. 3. Stricter goals will be instituted if the initial goals are not met. 4. It may be necessary to become involved with meal preparation.

1. The prearranged consequences will go into effect. The imposition of the prearranged consequences reinforces the agreed-upon contract; a behavior modification program must follow through consistently on issues of cause and effect. Death from starvation is not therapeutic; it is threatening. Goals are not changed; prearranged consequences are instituted when goals are not met. Working with food will not stimulate the client's eating; this is not therapeutic or productive.

A nurse is caring for a client with an obsessive-compulsive disorder. What is the basis for the obsessions and compulsions? 1. Unconscious control of unacceptable feelings 2. Conscious use of this method to punish themselves 3. Acceptance of voices that tell her that doorknobs are unclean 4. Fulfillment of a need to punish others by carrying out an annoying procedure

1. Unconscious control of unacceptable feelings In carrying out the compulsive ritual the client unconsciously tries to control anxiety by avoiding acting on unacceptable feelings and impulses. The client does not consciously use this method to punish herself. Hallucinations are not part of this disorder. People with obsessive-compulsive disorder feel no need to punish others.

What is essential for the nurse to do when approaching a client during a period of overactivity? 1. Using a firm but caring and consistent approach 2. Anticipating and physically controlling the hyperactivity 3. Allowing the client to choose the activities in which to participate 4. Letting the client know that the staff will not tolerate destructive behavior

1. Using a firm but caring and consistent approach Using a firm but caring and consistent approach will help reduce the client's anxiety, thereby reducing hyperactivity. It is not possible to physically control hyperactivity. The client is not capable of choosing activities at this time. The client may not be capable of controlling overactive behavior; setting verbal limits may not be effective.

While watching television in the dayroom a client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs from the room to the far end of the hallway. What is the most therapeutic intervention by the nurse? 1. Walking to the end of the hallway where the client is standing 2. Accepting the action as the impulsive behavior of a sick person 3. Asking another client in the dayroom why the client acted as she did 4. Documenting the incident in the client's record while the memory is fresh

1. Walking to the end of the hallway where the client is standing Walking to the end of the hallway where the client is standing lets the client know that the nurse is available. It also demonstrates an acceptance of the client. Accepting the action as the impulsive behavior of a sick person is an avoidance technique; it shows a lack of acceptance of the client as a person. Another client's perception of the incident may or may not be valid. Although it is important to document the incident in the client's record, this does not take precedence over letting the client know the nurse is available if needed.

A nurse is caring for a client with an antisocial personality disorder. What consistent approach should the nurse use with this client? 1. Warm and firm without being punitive 2. Indifferent and detached but nonjudgmental 3. Conditionally acquiescent to client demands 4. Clearly communicative of personal disapproval

1. Warm and firm without being punitive The client needs positive relationships with other adults, but clear, consistent limits must be presented to minimize attempts at manipulation. Being indifferent and detached but nonjudgmental is not a therapeutic approach. Being indifferent and detached gives the impression that the nurse does not care. Conditional acquiescence to client demands is not a therapeutic approach because clear, consistent limits are necessary to prevent manipulation. Being clearly communicative of personal disapproval is a judgmental attitude that should be avoided.

The wife of a client who has completed alcohol detoxification relates that she is concerned about her husband's behavior if he starts drinking again. She says, "When the drinking starts it really disrupts my family, and I'm not sure how to handle it." What is the best response by the nurse? 1. "Include your husband in the family's activities even when he's been drinking." 2. "Attend Al-Anon meetings and avoid assuming responsibility for your husband's behavior." 3. "Search the house regularly for hidden alcohol and accompany your husband outside the home." 4. "Help your husband avoid embarrassment by making excuses for him when it's impossible for him to function."

2. "Attend Al-Anon meetings and avoid assuming responsibility for your husband's behavior." Encouraging the wife to attend Al-Anon and to stop making excuses for the husband supports the family of the addicted individual and allows the family to continue on with life by reducing their guilt. Including the husband in the family's activities even when he has been drinking will be impossible to accomplish; the wife has stated that the drinking disrupts the family. Telling the wife to search the house regularly for hidden alcohol and to accompany her husband outside the home places the burden for preventing drinking on the family and will produce feelings of resentment and guilt. The husband must assume responsibility for his behavior resulting from the drinking. Telling the woman to help her husband avoid embarrassment by making excuses for him when it's impossible for him to function is enabling behavior, which does not help the abuser or the family.

A client undergoing alcohol detoxification asks about attending Alcoholics Anonymous (AA) meetings after discharge. What is the nurse's best initial reply? 1. "You'll find that you'll need their support." 2. "How do you feel about going to those meetings?" 3. "They'll help you to learn how to cope with your problem." 4. "Don't you think it's better to wait until you're sure that you're ready?"

2. "How do you feel about going to those meetings?" "How do you feel about going to those meetings?" focuses on the client's feelings rather than on the organization itself. The organization is effective only when the client is able to discuss his or her feelings openly without ridicule or judgment. "You'll find that you'll need their support" may or may not be true. "They'll help you to learn how to cope with your problem" is false reassurance; AA may help clients develop insight but may not be able to help them cope with their problems. "Don't you think it's better to wait until you're sure that you're ready?" does not focus on the client's feelings and may be discouraging.

A client tells the nurse, "All my friends experiment with drugs. I like the high I get when I huff paint. Nothing bad is going to happen to me." What is the best response by the nurse? 1. "Inhalants can cause a mild state of intoxication." 2. "Huffing paint can damage your lungs, kidneys, and liver." 3. "Withdrawal problems will start if you continue huffing paint." 4. "Limiting the type of inhalant used decreases respiratory irritation."

2. "Huffing paint can damage your lungs, kidneys, and liver." Inhaled toxins become systemic and cause damage to major organs such as the lungs, liver, and kidneys. Inhalants tend to produce euphoria, not just a mild state of intoxication. Huffing paint will not produce major withdrawal symptoms. All toxic substances that are inhaled become systemic and cause damage to major organs such as the lungs, liver, and kidneys.

A hospitalized client with an obsessive-compulsive disorder tells the nurse that coworkers and roommates get upset because she spends at least 30 minutes in the bathroom six times a day. The client says, "It keeps me from getting nervous." What is the most appropriate response by the nurse? 1. "That's not a problem now, because you have your own bathroom here." 2. "Tell me how spending time in the bathroom helps you avoid becoming nervous." 3. "Tell me more about what you do in the bathroom during those 30-minute periods." 4. "Let's start by cutting down the time you spend in the bathroom to 20 minutes three times a day."

2. "Tell me how spending time in the bathroom helps you avoid becoming nervous." The response "Tell me how spending time in the bathroom helps you avoid becoming nervous," encourages the client to explore the defenses employed to cope with anxiety. The response "That's not a problem now, because you have your own bathroom here," is a nontherapeutic response that denies the importance of a problematic area of behavior. The response "Tell me more about what you do in the bathroom during those 30-minute periods," focuses on tasks rather than feelings; also, it may be perceived as threatening or judgmental. The response "Let's start by cutting down the time you spend in the bathroom to 20 minutes three times a day," is a nontherapeutic response because it will worsen the client's anxiety. It is too early to start changing the behavior.

Which activity is most appropriate for a nurse to introduce to a depressed client during the early part of hospitalization? 1. Board game 2. Project involving drawing 3. Small aerobic exercise group 4. Card game with three other clients

2. Project involving drawing An art-type project that may be worked on successfully at one's own pace is appropriate for a depressed client. Board games and card games with three other clients require too much concentration and may increase the client's feelings of despair. This client is probably experiencing psychomotor retardation, and at this time an aerobic exercise group would not be appropriate.

After 4 days on the inpatient psychiatric unit a client on suicidal precautions tells the nurse, "Hey, look! I was feeling pretty depressed for a while, but I'm certainly not going to kill myself." What is the nurse's best response to this statement? 1. "You do seem to be feeling better." 2. "We should talk some more about this." 3. "We have to observe you until you're better." 4. "I don't understand what you mean by killing yourself."

2. "We should talk some more about this." The statement "We should talk some more about this" encourages the client to talk about feelings without the nurse setting the focus for the discussion. "You do seem to be feeling better" cuts off further communication of feelings; the client's statement may actually indicate a desire to act on the suicidal ideation. "We have to observe you until you're better" does not foster communication or a discussion of feelings. "I don't understand what you mean by killing yourself" will make the client wonder where the nurse has been for 4 days.

During a special meeting to discuss the unexpected suicide of a recently discharged client, a nurse overhears another client moan softly, "I'm next. Oh my God, I'm next. They couldn't protect him, and they can't protect me, either." What is the most therapeutic response by the nurse? 1. "That person was a lot sicker than you are." 2. "You seem to be afraid that you'll hurt yourself." 3. "That was different. He was at home, but you're here." 4. "There's no need to worry. We'll protect you even after you're discharged."

2. "You seem to be afraid that you'll hurt yourself." The statement "You seem to be afraid that you'll hurt yourself" identifies the importance of feelings and provides an opening for the client to talk about them. The client is not going to believe that the dead client was much sicker, and it is not helping the client to express such feelings. The nursing goal is to help people function outside the hospital environment and not be afraid to leave the hospital. Telling the client not to worry and that the staff will protect him or her is unrealistic and avoids the client's cry for help.

A client with agitation and mood swings approaches the nurse and shouts, "I've been watching you for a few days. You think you're so damned perfect and good. I think you stink." What is the most appropriate response by the nurse? 1. "Do you mean that I smell?" 2. "You seem to be angry with me." 3. "Wow, you're in a really bad mood." 4. "I can't really be all that bad, can I?"

2. "You seem to be angry with me." Observing that the client seems angry reflects on the client's feelings rather than focusing on the verbalization. Asking whether he client is referring to an odor focuses on the statement rather than on the feelings behind it. Stating that the client is in a bad mood dismisses the client and the client's feelings. Denying being "all that bad" puts the client on the defensive and asks for verification that the nurse is indeed a good person; it fails to focus on the feelings behind the statement.

A client who experiences auditory hallucinations agrees to discuss alternative coping strategies with a nurse. For the next 3 days when the nurse attempts to focus on alternative strategies, the client gets up and leaves the interaction. What is the most therapeutic response by the nurse? . "Come back; you agreed that you would discuss other ways to cope." 2. "You seem very uncomfortable every time I bring up a new way to cope." 3. "Did you agree to talk about other ways to cope because you thought that was what I wanted?" 4. "You walk out each time I start to discuss the hallucinations; does that mean you've changed your mind?"

2. "You seem very uncomfortable every time I bring up a new way to cope." "You seem very uncomfortable every time I bring up a new way to cope" focuses on a feeling that the client may be experiencing and provides an opportunity to validate the nurse's statement. "Come back; you agreed that you would discuss other ways to cope" demands that the client stay in an uncomfortable situation without offering any support. "Did you agree to talk about other ways to cope because you thought that was what I wanted?" fails to recognize the part anxiety plays in changing behavior. "You walk out each time I start to discuss the hallucinations; does that mean you've changed your mind?" seems like an attack on the client; also, although it offers an explanation for the behavior, it fails to convey an understanding that changing behavior is anxiety producing.

An adult client charged with molesting a child is admitted for psychiatric evaluation. When a nurse invites the client to come to dinner, the client refuses and says, "I don't want anyone to see me. Leave me alone." What is the best response by the nurse? 1. "Certainly. I'll respect your wishes." 2. "You sound upset; let's talk about it." 3. "It'll be easier to face other people right away." 4. "Only the staff members know why you're here."

2. "You sound upset; let's talk about it." "You sound upset; let's talk about it," identifies feelings and provides the client with an opportunity to talk. "Certainly. I respect your wishes," ignores the client's feelings and does not help the client cope with the situation. Whether it will be easier to face other people right away may or may not be true, so stating this constitutes false reassurance. The nurse does not know for a fact that only the staff members know why the client is there.

A hospitalized psychiatric client with the diagnosis of histrionic personality disorder demands a sleeping pill before going to bed. After being refused the sleeping pill, the client throws a book at the nurse. How does the nurse identify this behavior? 1. Exploitive 2. Acting out 3. Manipulative 4 Reaction formation

2. Acting out Acting out is the process of expressing feelings behaviorally. The action is not exploitive, because no evidence is provided to demonstrate that anyone has been used to get what the client wants. The action is not manipulative, because no evidence is provided to demonstrate that anyone has been influenced against his or her wishes. The action is not eaction formation, disguising unacceptable feelings by expressing opposite emotions.

A nurse works with school-age children who have conduct disorder, childhood-onset type. The nurse knows that these children are at risk for progression to another disorder during adolescence. For signs of which disorder should the nurse evaluate their current behavior? 1. Oppositional defiant 2. Antisocial personality 3. Pervasive developmental 4. Attention deficit hyperactivity

2. Antisocial personality Children who exhibit behaviors associated with conduct disorder before the age of 10, rather than during adolescence, have a higher incidence of antisocial personality disorder during adolescence. If oppositional defiant disorder persists for at least 6 months, it may be a precursor to a conduct disorder. Pervasive developmental disorders are characterized by impairments in reciprocal social interaction and communication skills; types include autistic, Asperger, Rett, and childhood disintegrative disorders. They are not preceded by conduct disorder. Attention deficit hyperactivity disorder is often dually diagnosed with oppositional defiant disorder or conduct disorder and may precede the development of Tourette syndrome.

A client with a borderline personality disorder is admitted to the mental health unit. What should the nurse do to maintain a therapeutic relationship with the client? 1. Provide an unstructured environment to promote self-expression 2. Be firm, consistent, and understanding and focus on specific target behaviors 3. Use an authoritarian approach because this type of client needs to learn to conform to the rules of society 4. Record but ignore marked shifts in mood, suicidal threats, and temper displays because these last only a few hours

2. Be firm, consistent, and understanding and focus on specific target behaviors Consistency, limit-setting, and supportive confrontation are essential nursing interventions designed to provide a secure, therapeutic environment for this client. To be therapeutic, the environment needs structure, and the staff must help the client set short-term goals for behavioral changes. The use of an authoritarian approach will increase anxiety in this type of client, resulting in feelings of rejection and withdrawal. Ignoring the client's behavior is nontherapeutic and may reinforce underlying fears of abandonment.

Which medication is used in the treatment of obsessive-compulsive disorder (OCD)? 1. Risperidone 2. Clomipramine 3. Carbamazepine 4. Lithium carbonate

2. Clomipramine Clomipramine is a tricyclic antidepressant used in the treatment of obsessive-compulsive disorder (OCD). Risperidone is used to treat schizophrenia. Carbamazepine and lithium carbonate are used to treat mood disorders.

A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of bingeing. Which clinical manifestation is most important for the nurse to evaluate? 1. Weight gain 2. Dehydration 3. Hyperactivity 4. Hyperglycemia

2. Dehydration The nurse should be alert for dehydration caused by fluid loss through vomiting in the binge-purge cycle. Weight gain is not expected because purging frequently follows a binge. Hyperactivity is not expected because many individuals with bulimia withdraw and vomit after a binge. Hyperglycemia is not expected because of the vomiting that follows a binge.

Despite repeated nursing interventions to improve reality orientation, a client insists that he is the commander of an alien spaceship. What is the client experiencing? 1. Illusion 2. Delusion 3. Confabulation 4. Hallucination

2. Delusion A delusion is a fixed false belief. An illusion is a false sense interpretation of an external stimulus. Confabulation is the client's attempt to fill gaps in memory with imaginary events. A hallucination is a false sensory perception with no external stimulus.

The nurse is caring for a client with vascular dementia. What does the nurse identify as the cause of this problem? 1. A long history of inadequate nutrition 2. Disruptions in cerebral blood flow, resulting in thrombi or emboli 3. A delayed response to severe emotional trauma in early adulthood 4. Anatomical changes in the brain that produce acute, transient symptoms

2. Disruptions in cerebral blood flow, resulting in thrombi or emboli Vascular dementia results from the sudden closure of the lumen of arterioles, causing infarction of the brain tissue in the affected area. Inadequate nutrition may be one of the factors that bring about a general decline of health; however, there is no direct evidence that avitaminosis causes primary degenerative dementia. Severe emotional trauma may contribute to but does not necessarily cause primary degenerative dementia. Neural degeneration leads to permanent, not transient, changes.

What should the nurse include when planning activities for an older nursing home resident with a diagnosis of dementia? 1. Varied activities that will keep the resident occupied 2. Familiar activities that the resident can complete successfully 3. Challenging activities to maintain the resident's contact with reality 4. Ways to ensure that the resident actively participates in the unit's daily activities.

2. Familiar activities that the resident can complete successfully Routines and familiarity with activities or the environment provide a sense of security. Change is tolerated poorly; frustration and the inability to accomplish tasks lead to lowered self-esteem. Decreased physical capacity and attention span limit active participation; frustration may result. Challenging activities may be frustrating and may lead to hostility or withdrawal.

When caring for clients who are at risk for suicide, what should the nurse consider? 1. A client who fails in a suicide attempt will probably not try again. 2. Formal suicide plans increase the likelihood that a client will attempt suicide. 3. It is best not to talk to clients about suicide because it may give them the idea. 4. Clients who talk about suicide are not planning it; they are using the threat to gain attention.

2. Formal suicide plans increase the likelihood that a client will attempt suicide. A formal plan demonstrates determination, concentration, and effort, with conclusions already thought out. Failure to successfully complete the suicidal act can add to feelings of worthlessness and stimulate further acts. Verbalizing feelings may help reduce the client's need to act out. Many clients verbalize their suicidal thoughts as they are working on their decision and plan of action; suicide may not be attempted just to receive attention.

An older resident in a nursing home who has a diagnosis of dementia hoards leftover food from the meal tray and other seemingly valueless articles and stuffs them into pockets "so the others won't steal them." What should the nurse plan to do? 1. Remove the resident's unsafe and soiled articles during the night 2. Give the resident a small bag in which to place selected personal articles and food 3. Explain to the resident why the nursing home's policy for cleanliness and safety must be followed 4. Explain to the resident that the staff is required to keep harmful objects out of reach in the resident's closet

2. Give the resident a small bag in which to place selected personal articles and food Giving the resident a small bag in which to place selected personal articles and food allows the client to exercise the right to decide which articles to keep and helps ensure safety and cleanliness. Removing the resident's unsafe and soiled articles during the night deceives the client and will create mistrust toward the staff. Because of the client's decreased attention span and memory, explanations alone will not help ensure safety or meet this client's needs. Telling the resident that the staff is required to keep harmful objects out of reach in the resident's closet does not address the client's needs; no data indicate that the resident is hoarding harmful objects.

A man with bipolar disorder, manic episode, has been traveling around the country, dating multiple women, and buying his dates expensive gifts. He is admitted to the hospital when he becomes exhausted and runs out of money. The nurse anticipates that during a manic episode the client is most likely experiencing which feelings? 1. Guilt 2. Grandeur 3. Worthlessness 4. Self-deprecation

2. Grandeur During a manic episode, a client has an inflated self-esteem (including feelings of grandeur) that replaces feelings with which the client cannot cope. Feelings of guilt, worthlessness, and self-deprecation are not associated with bipolar disorder, manic episode.

A young adult client is admitted to the hospital with a diagnosis of schizophrenia, paranoid type. The client has been saying, "The voices in heaven are telling me to come home to God." Initial nursing care should be focused on the client's: 1. Disturbed self-esteem 2. Potential for self-harm 3. Dysfunctional verbal communication 4. Impaired perception of environmental stimuli

2. Potential for self-harm Client safety always is the priority over any other client need, and command hallucinations increase the risk of injury. Although promoting self-esteem is important, this is not a priority at this time. There are no data to support the need to focus on the client's ability to verbally communicate. Verbal hallucinations occur within the individual; they are not precipitated by an environmental stimulus.

A frail, depressed client who frequently paces the halls becomes physically tired from the activity. What action should the nurse take to help reduce this activity? 1. Restrain the client in a chair 2. Have the client perform simple, repetitive tasks 3. Ask the client's health care provider to prescribe a sedative 4. Place the client in a single room to limit pacing to a smaller area

2. Have the client perform simple, repetitive tasks Clients who pace can usually be distracted by planned involvement in repetitious, simple tasks. The client's health care provider should be asked to prescribe a sedative only if the client's restlessness cannot be controlled with other measures and the physical exhaustion creates a danger. Restraining the client in a chair is abusive treatment for a client with a need to pace and reinforces the client's belief that punishment is required for redemption. The client may perceive being placed in a single room as a punishment, and it will limit the staff's ability to observe the client.

When answering questions from the family of a client with Alzheimer disease the nurse explains what about the disease? 1. It emerges in the fourth decade of life 2. It is a slow, relentless deterioration of the mind 3. It is functional in origin and occurs in the later years 4. It is diagnosed through laboratory and psychological tests

2. It is a slow, relentless deterioration of the mind Alzheimer disease is a slow and relentless deterioration of the mind; clients become progressively worse over time. The disease usually appears in people 60 years of age and older. Alzheimer disease is an organic, not a functional, disorder. At this time there are no diagnostic tools other than autopsy that can provide a definite confirmation of Alzheimer disease.

A client in a mental health facility is demonstrating manic-type behavior by being demanding and hyperactive. What is the nurse's major objective? 1. Easing the client's feelings of guilt 2. Maintaining a supportive, structured environment 3. Pointing out reality through continued communication 4. Broadening the client's contacts with other people on the unit

2. Maintaining a supportive, structured environment These clients are acutely aware of and sensitive to the environment; they need a structured environment in which stimuli are minimized and a feeling of acceptance and support is present. Lessening the client's feelings of guilt is a vague objective; it is not measurable. Pointing out reality through continued communication is not the priority. Reality orientation is not needed as much as maintaining a safe structured environment is. The client needs minimal, not increased, stimuli.

A 5-year-old with an attention deficit hyperactivity disorder (ADHD) exhibits a short attention span and demonstrates intermittent head-banging and hair-pulling, as well as excessive motor activity. What is the priority nursing objective for this child? 1. Facilitating sleep 2. Maintaining safety 3. Promoting body image 4. Increasing nutritional intake

2. Maintaining safety Excessive motor activity with intermittent head-banging and hair-pulling is self-destructive behavior that may result in injury; prevention of self-injury has the highest priority. Facilitating sleep, promoting body image, and increasing nutritional intake are not the most important nursing objectives in light of the data presented; prevention of self-injury is primary.

A client's admitting history indicates signs of akathisia. What clinical finding should the nurse expect when observing for this condition? 1. Facial tics 2. Motor restlessness 3. Maintaining a body position for hours 4. Repeating the movements of another person

2. Motor restlessness With akathisia the client exhibits a constant state of movement; this is characterized by restlessness and difficulty sitting still, including constant jiggling of the arms or legs. The distortion of voluntary movements, such as tics, spasms, or myoclonus, is known as dyskinesia. Maintaining a body position for hours is a form of catatonia known as waxy flexibility. Repeating the movements of another person is known as echopraxia.

A delusional client verbalizes the belief that others are out to harm him. A nurse notes the client's worsening pacing and agitation. What is the best nursing intervention? 1. Advising the client to use a punching bag 2. Moving the client to a quiet place on the unit 3. Encouraging the client to sit down for a while 4. Allowing the client to continue pacing with supervision

2. Moving the client to a quiet place on the unit A client losing control feels frightened and threatened; he or she needs external controls and a reduction in external stimuli. Advising the client to use a punching bag is helpful if the client is holding back aggressive behavior but is not useful in easing agitation associated with delusions. The client is unable, at this time, to sit in one place; his agitation is building. The client may get completely out of control if the pacing is allowed to continue.

On the fifth day of hospitalization the nurse notes that a depressed client remains lying on her bed when the clients are called to the dining room for lunch. What should the nurse do to encourage the client to eat? 1. Have a lunch tray sent to the client's room 2. Offer to accompany the client to the dining room 3. Explain that all clients are expected to go to the dining room for meals 4. Provide information about the importance of eating to maintain health

2. Offer to accompany the client to the dining room The client will be most likely to eat if accompanied and encouraged by an individual with whom a trusting relationship has been established. Having a lunch tray sent to the client's room is not likely to encourage the client to eat and will promote isolation. Explaining that all clients are expected to go to the dining room for meals will be ineffective at this time; the client is too introspective to care. The client's main concern at this point is not maintaining health, and she is not ready for teaching.

A client with a generalized anxiety disorder is hospitalized. The nurse determines that an environment conducive to reducing emotional stress and providing psychological safety for this client is one in which what happens? 1. Needs are met 2. Realistic limits and controls are set 3. The client's requests are met promptly 4. The client's environment is kept neat and orderly

2. Realistic limits and controls are set Setting realistic limits and controls makes the environment as emotionally nonthreatening as is realistically possible. All needs cannot be met; the person must learn how to cope with delaying gratification. It is not possible or realistic to meet all of a person's requests. Order in the environment is of less importance; providing a nonthreatening environment is the priority action.

During the admission procedure a client appears to be responding to voices. The client cries out at intervals, "No, no! I didn't kill him! You know the truth, tell that police officer! Please help me!" What is the most appropriate response by the nurse? 1. Listening attentively and assuming an expression of disbelief 2. Saying, "I want to help you. I realize that you must be very frightened." 3. Sitting quietly and refraining from responding to the client's statements 4. Saying, "Don't be so upset. No one is talking to you; those voices are part of your illness."

2. Saying, "I want to help you. I realize that you must be very frightened." Telling the client that help is available demonstrates an understanding of the client's feelings and encourages the client to share feelings, which is an immediate need. Sitting quietly and not responding to the client's statements will probably intensify the client's fears. Assuming an expression of disbelief is judgmental and demeaning to the client. Although telling the client not to be upset because no one is talking to him points out reality, it also gives a command that is unrealistic and closes the communication process.

On the afternoon of admission to a psychiatric unit, an adolescent boy with the diagnosis of schizophrenia exposes his genitals to a female nurse. What should the nurse's immediate therapeutic response be? 1. Ignoring the client at this time 2. Stating that this behavior is unacceptable 3. Moving him to his room for a short time-out 4. Telling the client to come to the office later to discuss the behavior

2. Stating that this behavior is unacceptable When clients enter a new milieu, limits should be set on unacceptable behavior and acceptable behavior should be reinforced. Neither clients nor unacceptable behavior should ever be ignored. Moving the client to his room for a short time-out is punishment. Unacceptable attention-getting behavior must be addressed immediately; also, the focus should be on appropriate behavior.

A client tells the nurse, "The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles." What is the best initial response by the nurse? 1. "Tell me whether the voices are male or female and how many there are." 2. "Don't worry; I've locked the door to your room and won't let anyone in." 3. "I understand that these voices are real to you, but I want you to know that I don't hear them." 4. "You should leave this room. Your mind needs to be occupied so the voices don't bother you."

3. "I understand that these voices are real to you, but I want you to know that I don't hear them." The statement "I understand that these voices are real to you, but I want you to know that I don't hear them" demonstrates recognition and acceptance of the client's feelings; it also points out reality. Encouraging the client to focus on a hallucination tends to strengthen and confirm the hallucination. The response "Don't worry; I've locked the door to your room and won't let anyone in" is false reassurance; the client has no reason to trust that the nurse can provide protection. Telling the client to leave this room and observing that the client's mind needs to be occupied so the voices don't bother him is nontherapeutic; it denies the client's feelings and may increase anxiety.

A client with an obsessive-compulsive disorder completes a compulsive ritual and says to the nurse, "Boy, you must really think I'm weird." What is the most appropriate response by the nurse? 1. "Are you weird?" 2. "Do you really think I feel that way?" 3. "It sounds like you're concerned about my feelings toward you." 4. "You do have a serious problem, but I don't think that you're weird."

3. "It sounds like you're concerned about my feelings toward you." The response "It sounds like you're concerned about my feelings toward you," addresses the client's concern and provides an opportunity to clarify the nurse's role in the therapeutic process. The response "Are you weird?" does not promote exploration of the client's feelings. The response "Do you really think I feel that way?" does not address the client's concern; also, it expects the client to interpret the nurse's thinking. The response "You do have a serious problem, but I don't think that you're weird," communicates that the client's problem is "serious" which may be discouraging for the client.

A client with a diagnosis of panic disorder who had a panic attack on the previous day says to the nurse, "That was a terrible feeling I had yesterday. I'm so afraid to talk about it." What is the most therapeutic response by the nurse? 1. "OK; we don't have to talk about it." 2. "Why don't you want to talk about it?" 3. "What were you doing yesterday when you first noticed the feeling?" 4. "I understand, but don't be concerned; that feeling probably won't come back."

3. "What were you doing yesterday when you first noticed the feeling?" The response "What were you doing yesterday when you first noticed the feeling?" helps the client focus on a situation that has precipitated frightening feelings. "OK; we don't have to talk about it?" avoids an opportunity for the nurse to help the client explore feelings. The client may not be able to answer the question "Why don't you want to talk about it?" The focus should be on feelings. The response "I understand, but don't be concerned; that feeling probably won't come back?" is false reassurance; the nurse cannot guarantee that the feelings will not come back.

One day the nurse and a young adult client sit together and draw. The client draws a face with horns and says, "This is me. I'm a devil." What is the best response by the nurse? 1. "I don't see a devil; why do you see a devil?" 2. "Let's go to the mirror to see what you look like." 3. "When I look at you I see a person, not a devil." 4. "You're not a devil; why do you talk about yourself like that?"

3. "When I look at you I see a person, not a devil." The response "When I look at you, I see a person, not a devil," points out reality while attempting to let the client understand that the nurse sees the client as a person of worth. The statement "I don't see a devil; why do you see a devil?" asks the client to explain his or her feelings, which may be unrealistic. The client may indeed view him- or herself as a devil. The statement "You're not a devil; why do you talk about yourself like that?" is a somewhat belittling response; it cuts off communication.

A 67-year-old man with type 2 diabetes sadly confides in the nurse that he has been unable to have an erection for several years. What is the best response by the nurse? 1. "At your age sex isn't that important." 2. "Sex isn't everything it's cracked up to be." 3. "You sound upset about not being able to have an erection." 4. "Maybe it's time for you to speak to your doctor about this."

3. "You sound upset about not being able to have an erection." When a client reveals something, it is important for the nurse to gather more information. The response "You sound upset about not being able to have an erection" promotes further communication. Assessment is the first step of the nursing process. "At your age sex isn't that important" is a subjective, judgmental response that reflects the nurse's view of sexuality in older adults. "Sex isn't what all it's cracked up to be" interjects the nurse's view and violates the concept of neutrality when counseling clients. Having the client speak to his health care provider may be indicated eventually, but first the nurse must obtain more information.

A client with a history of alcoholism returns to a previously attended in-house alcohol treatment program. What is the best initial statement by the nurse when the client returns to the facility? 1. "It's too bad that you failed this time. Do you think you might do better next time?" 2. "You could die of postnecrotic cirrhosis if you keep drinking. Doesn't that bother you?" 3. "You've made some progress. Now, let's start focusing on strategies to prevent a relapse." 4. "Hospitalization is useless unless you comply with the health team's recommendations.

3. "You've made some progress. Now, let's start focusing on strategies to prevent a relapse." Observing that the client has made some progress and that now the client and the nurse can focus on strategies for preventing relapses helps reinforce the client's small gains and provides encouragement for the future. Saying that it's unfortunate that the client has failed and asking whether the client thinks he or she will do better this time is a judgmental statement that focuses on the negative rather than the positive. Telling the client that he or she could die of cirrhosis if he or she keeps drinking and asking whether that bothers the client is a judgmental, negative response that is both nontherapeutic and incorrect; postnecrotic cirrhosis usually results from viral hepatitis. Telling the client that hospitalization is useless unless he or she complies with the health team's recommendations is a negative response and fails to recognize the client's role in rehabilitation.

The nurse is reviewing the medical data of four clients with depression. Which client is most likely to exhibit the clinical manifestation of irritability? 1. 2-year-old 2. 3-year-old 3. 13-year-old 4. 35-year-old

3. 13-year-old The 13-year-old client's depression is most likely to manifest as irritability. Depression in 2- and 3-year-old is more likely to manifest as apathy. Depression in the 35-year-old is more likely to manifest as fatigue.

A nurse becomes aware of an older client's feeling of loneliness when the client states, "I only have a few friends. My daughter lives in another state and couldn't care less whether I live or die. She doesn't even know I'm in the hospital." What does the nurse identify the client's communication as? 1. A call for help to prevent him from acting on suicidal thoughts 2. A manipulative attempt to persuade the nurse to call the daughter 3. A reflection of depression that is causing feelings of hopelessness 4. A request for information about social support groups in the community

3. A reflection of depression that is causing feelings of hopelessness This statement provides clues that the client feels no one cares, so there is no reason the client should care. These feelings are common in depression. The clues presented do not lead to the other conclusions.

A depressed client says, "I'm no good. I'm better off dead." What is the priority nursing intervention? 1. Responding, "I'll stay with you until you're less depressed." 2. Replying, "I think you're good; you should think about living." 3. Alerting the staff to schedule 24-hour observation of the client 4. Unobtrusively removing those articles that may be used in a suicide attempt

3. Alerting the staff to schedule 24-hour observation of the client Alerting the staff to schedule 24-hour observation of the client is the most therapeutic approach to preventing suicide. A staff member also provides special attention to help the client meet dependency needs and reduce a self-defeating attitude. Replying, "I think you're good; you should think about living." negates the client's feelings and cuts off further communication. Promising to stay with the client until the depression eases is unrealistic because the nurse cannot be with the client constantly until the depression lifts. Although potentially hazardous objects should be removed, the priority is 24-hour observation of the client.

Suicide precautions are ordered for a newly admitted client. What is the most therapeutic way to provide these precautions? 1. Keeping the client in the lounge during the daytime 2. Encouraging the client to express feelings frequently 3. Assigning a staff member to be with the client at all times 4. Having a nursing aide observe the client every half hour at night

3. Assigning a staff member to be with the client at all times Emotional support and close surveillance can demonstrate the staff's caring and their attempt to prevent the client from acting out of suicidal ideation. Although surveillance may meet the client's safety needs, it does not meet the client's emotional needs. Also, the client would still have the opportunity to attempt suicide at night. Encouraging the client to express feelings frequently is not a suicide precaution. Having a nursing aide check the client every half hour at night is unsafe; the client could still find a way to carry out a suicide attempt in the room.

A client on the psychiatric unit tells the nurse, "I'm a movie star, and the other clients are my audience." What is an appropriate conclusion for the nurse to document about what the client is experiencing? 1. Flight of ideas 2. Idea of reference 3. Delusion of grandeur 4. Auditory hallucination

3. Delusion of grandeur A delusion of grandeur is a fixed false belief that the person is a powerful, important person. A flight of ideas is an increase in the speed of thinking causing the person to shift from one idea to another without completing the previous idea; it is often expressed with pressured speech. An idea of reference is an incorrect interpretation of an external event as having a special meaning to the person. An auditory hallucination is experienced when a person hears voices without external stimuli.

After a cocaine binge an individual is found unconscious and is admitted to the hospital with acute cocaine toxicity. What should the initial nursing action be directed toward? 1. Being understanding 2. Maintaining a drug-free environment 3. Establishing a patent airway 4. Establishing a therapeutic relationship

3. Establishing a patent airway The client is unconscious and unable to meet physical needs; a patent airway, breathing, and circulation are essential needs. Understanding and support are important once the client's physical condition has stabilized. Maintaining a drug-free environment will be a priority later in the treatment program. Establishment of a therapeutic relationship will increase in importance once the client's physical condition has stabilized.

A client is admitted to the psychiatric service with a diagnosis of severe depression. When approached by the nurse, the client says, "You know I'm a sorry, lazy person. I don't deserve a job. I'm just stupid and no good." What does the nurse conclude that the client is experiencing? 1. Nihilistic delusions 2. Delusions of persecution 3. Feelings of self-deprecation 4. Experiences of depersonalization

3. Feelings of self-deprecation The client's statements are self-derogatory and reveal low self-esteem. There is no evidence of feelings about nonexistence. There is no evidence that the client feels controlled or manipulated by others. There is no evidence that the client has a feeling of unreality or of alienation from the self.

A nurse is caring for a client who uses ritualistic behavior. What common antiobsessional medication does the nurse anticipate will be prescribed? 1. Benztropine (Cogentin) 2. Amantadine (Symmetrel) 3. Fluvoxamine (Luvox) 4. Diphenhydramine (Benadryl)

3. Fluvoxamine (Luvox) Fluvoxamine (Luvox) blocks the uptake of serotonin, which leads to a decrease in obsessive-compulsive behaviors. Benztropine (Cogentin) is an antiparkinsonian agent, not an antianxiety agent. Amantadine is an antiparkinsonian agent, not an antianxiety agent. Diphenhydramine (Benadryl) is an antihistamine, not an antianxiety agent.

Which statement regarding anxiety is correct? 1. Panic is a chronic form of anxiety. 2. Anxiety trait is a learned response to an event such as test-taking. 3. Generalized anxiety disorder is characterized by a severe degree of avoidance behavior. 4. Signal anxiety is associated with a feeling of dread with a source that cannot be identified.

3. Generalized anxiety disorder is characterized by a severe degree of avoidance behavior. Generalized anxiety disorder is characterized by a high degree of anxiety or avoidance behavior. Panic is an acute, not chronic, form of anxiety. Anxiety trait is learned but is not in response to a specific event. Signal anxiety is a learned response to a specific event such as test-taking.

An older client is transferred to a nursing home from a hospital with a diagnosis of dementia. One morning, after being in the nursing home for several days, the client is going to join a group of residents in recreational therapy. The nurse sees that the client has laid out several outfits on the bed but is still wearing nightclothes. What should the nurse do? 1. Help the client dress and explain when residents are expected at the activity 2. Prompt the client to dress more quickly to avoid delaying the other residents 3. Help the client select appropriate attire and offer to help the client get dressed 4. Allow the client time to dress but explain that client has missed the opportunity to attend the activity

3. Help the client select appropriate attire and offer to help the client get dressed Helping the client select appropriate attire and offering help in getting dressed aid the client in decision-making; new situations may be stressful and may lead to ambivalent feelings. Helping the client dress and explaining when residents are expected at the activity are not sharing decision-making; the client may not remember this explanation in the future. Reminding the client to dress more quickly to avoid delaying the other residents may make the client feel guilty and may increase

Which nursing action is most important when providing counseling to an adolescent with anorexia nervosa? 1. Avoiding talk of food 2. Limiting discussion of trivial topics 3. Helping the client express concerns about body image 4. Identifying the role played by the parents in the development of the disorder

3. Helping the client express concerns about body image Expression of thoughts, feelings, and concerns helps the client clarify eventually the underlying factors of the disorder, which may be associated with issues such as identity, intimacy, sexuality, and adult responsibilities. Food can be discussed with a matter-of-fact approach as long as the talk is not pervasive, authoritarian, or guilt producing. Helping the client express concerns about body image may interfere with the nurse-client relationship; the nurse must listen because what appears trivial or insignificant to the nurse may not be trivial or insignificant to the adolescent. Blame for the disorder should not be placed on anyone.

A client has been hospitalized for 3 weeks while receiving a tricyclic medication for severe depression. One day the client says to the nurse, "I'm really feeling better; my energy level is up." After the encounter an aide tells the nurse that the client has given away his favorite jacket. What should the nurse conclude that the client's statement indicates? 1. Improved mood 2. Improved socialization 3. Increased risk for suicide 4. Heightened need for independence

3. Increased risk for suicide When the energy level improves in the depressed client, the risk for suicide increases; also, the client has given away a personal belonging, which may indicate a plan to commit suicide. Elevated mood may be true, but the gift of a cherished personal belonging decreases the possibility that the client's statement simply reflects an improvement in mood. The client's socialization may be improved, but the gift of a valuable personal belonging decreases the possibility that the act simply reflects an improved level of socialization. Giving something away is unrelated to independence.

A nurse considers the cultural factors that may influence the development of eating disorders. The nurse recalls that eating disorders exist more frequently where? 1. Affluent families 2. European countries 3. Industrialized societies 4. Men rather than women

3. Industrialized societies Eating disorders are prevalent in industrialized societies that have an abundance of food; affected individuals likely equate food with pleasure, comfort, and love and may have been nurtured, punished, or rewarded with food. Eating disorders occur in all socioeconomic groups. The incidence and prevalence of eating disorders around the world are similar in European countries, the United States, Canada, Mexico, Japan, Australia, and other Westernized countries with plentiful food supplies. Studies indicate that 95% to 99% of persons with eating disorders are women, not men.

The clients on a mental health unit go on a supervised day trip to a baseball game. When returning to the bus, a client with a narcissistic personality disorder insists on leaving the group to get an autograph from a player. What is the most appropriate response by the nurse? 1. Holding the client by the arm to keep her from leaving the group 2. Instructing the client in a loud voice to get on the bus so the group can go home 3. Informing the client in a matter-of-fact tone that everyone must remain with the group 4. Telling the client that the baseball player will not be permitted to give anyone an autograph

3. Informing the client in a matter-of-fact tone that everyone must remain with the group Informing the client in a matter-of-fact tone indicates that negotiation is unacceptable. Holding the client by the arm is an inappropriate use of force. The nurse should contact the police if the client continues to refuse to leave. Raising the voice to a client indicates frustration and may be interpreted as threatening. Using the baseball player to meet control issues indicates to the client that the nurse is unable to maintain control of the situation.

The parents of a child with attention deficit hyperactivity disorder ask the nurse about using medication. What is the most frequently prescribed medication for this disorder? 1. Lorazepam (Ativan) 2. Haloperidol (Haldol) 3. Methylphenidate (Ritalin) 4. Methocarbamol (Robaxin)

3. Methylphenidate (Ritalin) Methylphenidate (Ritalin) appears to act by stimulating release of norepinephrine from nerve endings in the brainstem. Lorazepam (Ativan) is a benzodiazepine used to treat anxiety and insomnia. Haloperidol (Haldol) is an antipsychotic medication. Methocarbamol (Robaxin) is a muscle relaxant.

How should the nursing staff fulfill the nutritional needs of a client experiencing periods of extreme mania and hyperactivity? 1. Accepting that the client will eat when hungry 2. Allowing the client to prepare meals to eat when desired 3. Offering high-calorie snacks frequently that the client can hold 4. Leaving food in the client's room that can be eaten when desired

3. Offering high-calorie snacks frequently that the client can hold Hyperactive clients burn up many calories, which must be replenished. Because such clients will not take the time to sit down to eat, providing them with food that they can carry sometimes helps. The client will probably not be aware of hunger and may go without food for a dangerously long time. The client is not capable of preparing food at this time. The client probably will not be aware of hunger and will not independently initiate eating.

A client who is being treated for schizophrenia, paranoid type, arrives at the clinic demonstrating a shuffling gait and tilting his head toward one shoulder. What should the nurse conclude about these clinical manifestations? 1. Expected characteristics of this illness 2. Consistent with an acute exacerbation of the illness 3. Possible side effects of the antipsychotic medication 4. Life-threatening and requiring immediate intervention

3. Possible side effects of the antipsychotic medication Shuffling gait and torticollis are symptoms of pseudoparkinsonism that are caused by antipsychotic medications, particularly the typical antipsychotics. Expected characteristics of schizophrenia, paranoid type, include delusions, hallucinations, suspiciousness, anger, hostility, and paranoia. Although these physical manifestations require intervention, they are not life threatening. An acute exacerbation of the illness reflects an increased intensity of the expected characteristics associated with paranoid schizophrenia, which include pressured speech, suicidal ideation, and aggressive, agitated behavior.

An older adult client is talking to the nurse about his Vietnam experiences and shares that he still has flashbacks. While sitting with him the nurse notices that he is jumpy and exhibits startle reactions and poor concentration. The nurse identifies these as symptoms of what? 1. Delusions 2. Hallucinations 3. Posttraumatic stress disorder (PTSD) 4. Obsessive-compulsive disorder (OCD

3. Posttraumatic stress disorder (PTSD) PTSD is a syndrome characterized by the development of symptoms after an extremely traumatic event. Symptoms include helplessness, flashbacks, intrusive thoughts, memories, images, emotional numbing, loss of interest, avoidance of any place that reminds the affected person of the traumatic event, poor concentration, irritability, startle reactions, jumpiness, and hypervigilance. Delusions are beliefs that guide one's interpretation of events and help make sense of disorder. Common delusions among older adults involve being poisoned, having their assets taken by their children, being held prisoner, and being deceived by a spouse or lover. Hallucinations are visual or auditory perceptions of nonexistent objects and sounds. Older adults with hearing and vision deficits may hear voices or see people who are not actually present. OCD is characterized by recurrent and persistent thoughts, impulses, and images that are repetitive and purposeful and intentional urges of ritualistic behaviors that improve the affected person's comfort level.

A client who has been hospitalized with schizophrenia tells the nurse, "My heart has stopped, and my veins have turned to glass!" What should the nurse conclude that the client is experiencing? 1. Echolalia 2. Hypochondriasis 3. Somatic delusion 4. Depersonalization

3. Somatic delusion A somatic delusion is a fixed false belief about one's body. Echolalia is the automatic and meaningless repetition of another's words or phrases. Hypochondriasis is a severe, morbid preoccupation with an unrealistic interpretation of real or imagined physical symptoms. Depersonalization is a feeling of unreality and alienation from one's self.

A client with a borderline personality disorder receives the wrong meal tray for lunch and angrily states, "The next time I see the dietitian, I'm going to throw this tray at her!" What is the most appropriate response by the nurse? 1. Suggesting that the client calm down and explaining that sometimes trays get mixed up 2. Informing the client that the behavior is inappropriate and sending the client out of the dining room 3. Telling the client that it is frustrating not to get the correct tray but that throwing the tray at the dietitian is unacceptable behavior 4. Informing the client that throwing the tray at the dietitian will make matters worse and may result in his being placed in seclusion

3. Telling the client that it is frustrating not to get the correct tray but that throwing the tray at the dietitian is unacceptable behavior Validating the client's frustration and correcting the behavior are the most appropriate responses; safety is a priority. Suggesting that the client calm down and explaining that sometimes trays get mixed up does not validate the client's feelings. Sending the client out of the room without offering support and direction is not an appropriate nursing response. Threatening seclusion is an inappropriate nursing intervention.

Evaluation of clients with anorexia nervosa requires reassessment of behaviors after admission. Which finding indicates that the therapy is beginning to be effective? 1. Food is hidden in the client's pockets. 2. The client states that the hospitalization has been helpful. 3. The client has gained 6 lb since admission 3 weeks ago. 4. The client remains in the dining room eating for 1 hour after others have left.

3. The client has gained 6 lb since admission 3 weeks ago. Weight gain of 6 lb since admission 3 weeks ago is objective proof that the client's eating behaviors have improved. "Stashing" of food is a characteristic of an eating disorder, not a sign of improvement. The statement that the hospitalization has been helpful is subjective information and may be manipulative. "Marathon meals" with little actual food ingestion are common in people with anorexia and do not indicate improvement.

How should a nurse intervene when a confused and anxious client voids on the floor in the sitting room of the mental health unit? 1. Make the client mop the floor 2. Restrict the client's fluids for the rest of the day 3. Toilet the client more frequently with supervision 4. Withhold the client's privileges each time the client voids on the floor

3. Toilet the client more frequently with supervision The client is voiding on the floor not to express hostility but because of confusion. Taking the client to the toilet frequently reduces the risk of voiding in inappropriate places. Making the client mop the floor is a form of punishment for something the client cannot control. Restricting the client's fluids for the rest of the day is not realistic; it will have no effect on the problem and may lead to physiological problems. If the client were doing this to express hostility, withholding privileges might be effective, but not when the client is unable to control the behavior.

A nurse's best approach when caring for a confused older client is to provide an environment with what? 1. Space for privacy 2. Group involvement 3. Trusting relationships 4. Activities that are varied

3. Trusting relationships A trusting one-on-one relationship is essential to help the client become more involved and interested in interpersonal relationships. Privacy is usually not an issue for a confused client, who requires increased supervision. A confused individual needs to start with a one-on-one relationship before progressing to group involvement. Selected activities, rather than a large variety of activities, are best.

A nurse is caring for a client with antisocial personality disorder. What client characteristic should the nurse consider when formulating a plan of care? 1. Suffers from extreme anxiety 2. Rapidly learns by experience if punished 3. Usually is unable to postpone gratification 4. Has a great sense of responsibility toward others

3. Usually is unable to postpone gratification Individuals with antisocial personality disorder tend to be self-centered and impulsive. They lack judgment and self-control and are unable to postpone gratification. Generally they do not suffer from anxiety. These individuals believe that the rules do not apply to them, and they do not learn from their mistakes. These people are too self-centered to have a sense of responsibility to anyone.

An older client is hospitalized with the diagnosis of dementia of the Alzheimer type. The son tearfully tells the nurse, "I should never have allowed my father to live alone like he wanted to do, but he hasn't been this bad! I'm to blame! He didn't even recognize me right off the bat." What response by the nurse is most therapeutic? 1. "I don't think that anybody can blame you. You did what he wanted. Your being here tells us that you care." 2. "I realize that you're upset now. You can visit again when he is more responsive. I'm sure you'll see a change." 3. "Why do you think your father's condition has deteriorated? His forgetfulness is temporary. You'll help if you don't cry." 4. "This must be a difficult time for both of you. Please share some of your other observations with us that will help us plan his care."

4. "This must be a difficult time for both of you. Please share some of your other observations with us that will help us plan his care." Noting that this must be a difficult time for both father and son and asking the son to share some of his other observations to help the nursing staff plan the father's care focuses on feelings and promotes verbalization, which may ease anxiety and feelings of guilt. Also, it may help the son feel useful. Saying that no one could blame the son because he did what the father wanted and telling the son that his presence indicates caring is a generalized personal opinion; the nurse at this time does not know about the family's relationships. Telling the son that the father will certainly show a change in his behavior provides false reassurance. Asking the son why he thinks that his father's condition has deteriorated is confrontational and may precipitate a defensive response. Moreover, dementia of the Alzheimer type is not temporary and crying should not be discouraged because it helps relieve tension.

A client confides to the nurse that she enjoys engaging in sex with multiple male adult sex partners simultaneously. What is the most appropriate response by the nurse? 1. "I recommend that you seek counseling for this problem." 2. "Don't you think that having sex with multiple partners is immoral?" 3. "These men are abusing you, and you should go to the police to report them." 4. "What are you using for birth control and protection from sexually transmitted infections?"

4. "What are you using for birth control and protection from sexually transmitted infections?" Adults may have consensual sex as desired, but the nurse should encourage the use of birth control and protection from sexually transmitted infections. The nurse is interjecting personal values by stating that the client should seek counseling for this behavior or that the client's behavior is immoral. If the sex is consensual, it is not abusive.

Which is a clinical manifestation of a panic attack? 1. Confusion 2. Hallucinations 3. Substance abuse 4. A sensation of choking

4. A sensation of choking Panic attacks are characterized by several clinical manifestations including the sensation of choking. Confusion is experienced by clients with many different conditions but is not specific to a panic attack. Clients with schizophrenia are likely to experience hallucinations. Substance abuse is a characteristic feature of personality disorder.

A nurse is providing information about Alcoholic Anonymous (AA) meetings to a client with a history of alcohol abuse. What will be required when the client attends AA meetings? 1. Speaking aloud at weekly meetings 2. Maintaining controlled drinking after 6 months 3. Promising to attend at least 12 meetings yearly 4. Acknowledging an inability to control the alcoholism

4. Acknowledging an inability to control the alcoholism A major premise of AA is that to be successful in achieving sobriety, clients with an alcohol abuse problem must acknowledge their inability to control the use of alcohol. There are no rules of attendance or speaking at meetings, although both actions are strongly encouraged. Maintaining controlled drinking after 6 months is not part of the AA program; this group strongly supports total abstinence for life.

A nurse is discussing plans with a client who has decided to withdraw from alcohol. What should the nurse recommend as one of the most effective treatments for alcoholism? 1. Individual or group psychotherapy 2. Admission to an alcoholic unit in a hospital 3. Daily administration of disulfiram (Antabuse) 4. Active membership in Alcoholics Anonymous

4. Active membership in Alcoholics Anonymous Members find empathy, patience, and understanding in Alcoholics Anonymous (AA). They are able to have their dependence needs met while helping others who are even more dependent. Individual or group psychotherapy is helpful, but it does not have the success rate of AA. Admission to an alcoholic unit in a hospital is important for the detoxification stage, not for overall therapy. Daily administration of disulfiram (Antabuse) may be helpful for some clients, but it does not have the success rate of AA.

A client with the diagnosis of obsessive-compulsive disorder uses paper towels to open doors to avoid touching dirty doorknobs. How should the nurse respond initially to this behavior? 1. By explaining that the towels are dirty 2. By preventing the client from using towels 3. By removing the paper towels from the area 4. By allowing the behavior for the time being

4. By allowing the behavior for the time being A therapeutic relationship is easier to establish when anxiety is eased; the use of paper towels may ultimately facilitate communication. Preventing the client from using towels may increase anxiety further, thus hindering the development of a therapeutic relationship. Telling the client that the towels are dirty reinforces the use of dirt as a defense against real feelings and will worsen the client's anxiety. Removing the paper towels from the area may increase anxiety further, thereby hindering the development of a therapeutic relationship.

A practitioner prescribes disulfiram (Antabuse) for a client who abuses alcohol. The nurse remembers that disulfiram will do what? 1. Affect short-term memory 2. Permit a healthier lifestyle 3. Allow him to tolerate small amounts of alcohol 4. Cause a severe adverse reaction if alcohol is consumed

4. Cause a severe adverse reaction if alcohol is consumed Disulfiram is an aversion therapy; a person who consumes alcohol while taking disulfiram will experience a severe reaction consisting of nausea, vomiting, hypotension, headache, tachycardia, tachypnea, and flushing. The drug does not affect short-term memory. Use of disulfiram may or may not foster a healthier lifestyle, and if it does occur this is the result of multiple factors, not just disulfiram therapy. When taking disulfiram the client cannot tolerate any alcohol.

When talking with the nurse, a client with a mood disorder says, "I feel rotten. I feel useless. I can't think straight. I feel overwhelmed by everything. I don't know if I can go on." What should the nurse document when describing this encounter? 1. Client stated, "I can't think straight," and is not able to cope with current problems. 2. Client appeared to be very depressed for most of the morning and has little interest in self or the environment. 3. Client expressed suicidal thoughts about not being able to go on and exhibits diminished ability to think clearly. 4. Client stated, "I feel rotten. I feel useless. I can't think straight. I feel overwhelmed by everything. I don't know if I can go on."

4. Client stated, "I feel rotten. I feel useless. I can't think straight. I feel overwhelmed by everything. I don't know if I can go on." Directly quoting the client, with no added value judgments, is an objective documentation of what happened. Writing down part of what the client said ("I can't think straight") and then concluding that the client can't cope reflects a subjective judgment and an interpretation of what the client actually said. Noting that the client appeared very depressed for most of the morning and showed little interest in self or the environment is a subjective judgment and an interpretation of what the client actually said. Documenting that the client expressed suicidal thoughts about not being able to go on and has a decreased ability to think clearly is a subjective judgment and an interpretation of what the client actually said.

Which therapy is focused on breaking negative thought patterns and developing positive feelings about memories? 1. Play therapy 2. Group therapy 3. Behavior therapy 4. Cognitive therapy

4. Cognitive therapy Cognitive therapy is focused on breaking negative thought patterns and developing positive feelings about memories. Play therapy helps children express their feelings through the use of toys as their "spokesperson" of feelings. In group therapy, a group of clients with similar psychological problems work together to attain insight through discussion and role-playing. Behavior therapy is used to resolve phobias.

Which personality disorder is classified in cluster C? 1. Schizoid 2.Borderline 3. Narcissistic 4. Dependent

4. Dependent Dependent personality disorder is classified under cluster C; cluster C disorders include those that involve anxious, fearful behavior. Schizoid personality disorder is classified in cluster A, which includes disorders involving odd or eccentric behavior. Borderline personality disorder and narcissistic personality disorder are classified under cluster B, which includes behaviors that are dramatic, emotional, or erratic.

Which personality disorder is characterized by anxious and fearful behavior? 1. Schizoid personality disorder 2. Paranoid personality disorder 3. Narcissistic personality disorder 4. Dependent personality disorder

4. Dependent personality disorder Dependent personality disorder is characterized by anxious and fearful behavior. Schizoid and paranoid personality disorders are characterized by eccentric behavior. Narcissistic personality disorder is characterized by dramatic, emotional, or erratic behavior.

Nurses working with clients who have a diagnosis of dementia should adopt a common approach of care because these clients need to do what? 1. Relate in a consistent manner to staff 2. Learn that the staff cannot be manipulated 3. Accept controls that are concrete and fairly applied 4. Have sameness and consistency in their environment

4. Have sameness and consistency in their environment A consistent approach and consistent communication from all members of the health team help the client who has dementia remain more reality oriented. It is the staff members who need to be consistent. Clients who have this disorder do not attempt to manipulate the staff. Acceptance of controls that are concrete and fairly applied is not needed when working with clients who have this disorder; consistency is most important.

A client with schizophrenia is admitted to an acute care psychiatric unit. Which clinical findings indicate positive signs and symptoms of schizophrenia? 1. Withdrawal, poverty of speech, inattentiveness 2. Flat affect, decreased spontaneity, asocial behavior 3. Hypomania, labile mood swings, episodes of euphoria 4. Hyperactivity, auditory hallucinations, loose associations

4. Hyperactivity, auditory hallucinations, loose associations Hyperactivity, auditory hallucinations, and loose associations are positive symptoms of schizophrenia; positive symptoms reflect a distortion or excess of normal function. Hypomania, labile mood swings, and episodes of euphoria are associated with bipolar disorder, manic episode. Flat affect, decreased spontaneity, and asocial behavior and hyperactivity, auditory hallucinations, and loose associations are all negative symptoms associated with schizophrenia; negative symptoms reflect a diminution or absence of normal function.

An adult client with schizophrenia is involuntarily admitted to the psychiatric unit. While off the unit for needed testing, the client runs away. Legally, who should the nurse notify immediately? 1. Probate judge 2. Client's family 3. Client's psychiatrist 4. Law enforcement officer

4. Law enforcement officer Legally it is the responsibility of the staff to notify law enforcement officers so the client can be apprehended. A judge may be involved later in a nonemergency situation. Although the client's family and psychiatrist will be notified eventually, neither is the priority.

What is the priority nursing objective of the therapeutic psychiatric environment for a confused client? 1. Helping the client relate to others 2. Making the hospital atmosphere more homelike 3. Helping the client become accepted in a controlled setting 4. Maintaining the highest level of safe, independent function

4. Maintaining the highest level of safe, independent function The therapeutic milieu is directed toward helping the client develop effective ways of functioning safely and independently. Helping the client relate to others is one small part of the overall objectives. The therapeutic milieu allows some items from home to make the client less anxious; however, the objective is not to duplicate a home situation. Helping the client become accepted in a controlled setting is a worthwhile objective but not as important as working toward the maximal degree of safe, independent function.

An obviously upset client comes to the mental health clinic and, after pushing ahead of the other clients, states, "I had an argument with my daughter, and now I'm tense, and worried, and angry." What level of anxiety does the nurse determine that the client is experiencing? 1. Mild 2. Panic 3. Severe 4. Moderate

4. Moderate The client is focused on one part of reality but is unable to grasp the total picture; this situation reflects a moderate level of anxiety. Mild anxiety is the level at which the individual is cognizant of all aspects of reality but has a "jumpy feeling" and "butterflies in the stomach." Panic is the level at which the individual is no longer in contact with reality, is unable to make decisions, has impaired judgment, and is dysfunctional. Severe anxiety is the level at which individuals lose touch with reality and have a feeling of impending doom, which tends to immobilize them.

Which finding best describes voyeurism? 1. Wearing clothes of the opposite sex 2. Touching and rubbing against a nonconsenting individual 3. Exposing one's genitals to one or more unsuspecting people 4. Obtaining sexual gratification by watching others engaging in intercourse

4. Obtaining sexual gratification by watching others engaging in intercourse Voyeurism is a paraphilic disorder in which the person obtains sexual gratification by watching others as they engage in intercourse and by looking at other people's genitals. Wearing clothes of the opposite sex to achieve sexual gratification is known as transvestic fetishism. Touching and rubbing against a nonconsenting individual is known as frotteurism. Exposing one's genitals to one or more unsuspecting persons to achieve sexual arousal is known as exhibitionism.

A nurse is caring for a client during the manic phase of bipolar disorder. What should the nurse do to best help meet the nutritional needs of this client? 1. Provide a tray in the client's room 2. Assure the client that the food is deserved 3. Point out that the energy the client is burning up must be replaced 4. Order foods that the client can hold in the hand to eat while moving around

4. Order foods that the client can hold in the hand to eat while moving around The hyperactive client should be given handheld foods that do not require sitting down to eat. The client most likely will ignore a tray. Unworthy feelings may be part of a depressive, not manic, episode. It is unlikely that the client will understand or care about the need to replenish lost energy.

A man has completed an alcohol detoxification program and is setting goals for rehabilitation. When setting goals it is important for this client to understand the need to do what? 1. Plan to avoid people who drink 2. Accept that he is a fragile person 3. Develop new social drinking skills 4. Restructure his life without alcohol

4. Restructure his life without alcohol Clients must learn new lifestyles and coping skills to maintain sobriety. Planning to avoid people who drink is an unrealistic, unattainable plan. Accepting that he is a fragile person is judgmental, negative thinking that will lower self-esteem. Abstinence is essential; social drinking is not an option

An individual whose employment has been terminated because his company has been acquired by another company is brought by a family member to the mental health clinic because of extreme depression. While talking with the nurse the client says, "I'm a useless, worthless person. No wonder I lost my job." What type of delusion does the nurse identify? 1. Reference 2. Persecution 3. Alien control 4. Self-deprecation

4. Self-deprecation The client's statement is self-derogatory and reflects a low self-appraisal. There is no evidence that the client feels that he is the object of attention from others in the environment, that the client feels harassed, or that the client feels that others are controlling or manipulative.

What sexual disorder does a client who finds punishment necessary to achieve sexual gratification have? 1. Sadism 2. Frotteurism 3. Transsexualism 4. Sexual masochism

4. Sexual masochism Sexual masochism is a sexual disorder in which a person requires punishment to achieve sexual gratification. Sadism refers to the need to inflict pain or humiliation on another person to achieve sexual gratification. Frotteurism is a sexual disorder in which sexual arousal is achieved by rubbing against or touching a nonconsenting individual. Transsexualism is a condition in which a person has a persistent desire to be and to have the body of the opposite sex.

A 7-year-old boy is brought to the clinic by the mother, who tells the nurse that her child has been having trouble in school, has difficulty concentrating, and is falling behind in schoolwork since she and her husband separated 6 months ago. The mother reports that lately her child has not been eating dinner, and she often hears him crying when he is alone. What basis for these behaviors should the nurse consider? 1. The child feels different from his classmates. 2. The child will be happier living with the father. 3. The child is working through feelings of shame. 4. The child may be blaming himself for his parents' breakup.

4. The child may be blaming himself for his parents' breakup. Children usually blame themselves for their parents' marital problems, believing that they are the reason that a parent leaves. No data are presented to indicate that the child feels different from his peers, that he will be happier living with his father, or that he is working through feelings of shame.

A client has a persistent desire to have the body of the opposite sex and likes cross-dressing. Which paraphilia is associated with the client's condition? 1. Sadism 2. Pedophilia 3. Sexual masochism 4. Transvestic fetishism

4. Transvestic fetishism A client with transsexualism has a persistent desire to be and to have the body of the opposite sex. Transvestic fetishism is a paraphilia associated with transsexualism that involves wearing clothing of the opposite sex to obtain sexual gratification. Sadism involves hurting or humiliating another person to achieve sexual arousal. Pedophilia involves pursuing sexual activities with a prepubescent child by an adult. Sexual masochism is a condition in which a person achieves sexual arousal by being subjected to mental or physical abuse.

A client with bulimia nervosa eats two sandwiches, two salads, and four desserts for lunch. What client behavior should the nurse anticipate after the meal is consumed? 1. Excessive exercise 2. Hoarding of more food for a later binge 3. Active socializing with small groups of clients 4. Withdrawing from the group to go to the bathroom

4. Withdrawing from the group to go to the bathroom Bulimia is characterized by the binge-purge cycle; most clients withdraw from others and vomit after an eating binge. Although some individuals with bulimia may exercise to excess, this is a more common finding with the diagnosis of anorexia nervosa. Although individuals with bulimia may hoard food, this behavior commonly occurs later, when limits are put on their intake. Most individuals with bulimia do not seek support or socialization after a binge, although they may socialize at other times.

A delirious client sees a design on the wallpaper and perceives it as an animal. In the change-of-shift report, how should the nurse communicate what the client perceived? 1. A delusion 2. An illusion 3. A hallucination 4. An idea of reference

An illusion is a misperception or misinterpretation of an actual external stimulus. A delusion is a false belief that cannot be changed even by evidence; it is associated with psychosis. A hallucination results from an imaginary, not real, stimulus. An idea of reference is a belief that others are talking about the person.

An older adult resident of a nursing home who has the diagnosis of dementia of the Alzheimer type, frequently talks about the good old days at the ranch. What is the most appropriate action by the nurse? 1. Allowing the resident to reminisce about the past and listening with interest 2. Involving the resident in interesting diversional activities with a small group 3. Reminding the resident that those "good old days" are past and that he or she should focus on the present 4. Introducing the resident to other residents with the same diagnosis so that they can share their past experiences

1. Allowing the resident to reminisce about the past and listening with interest Allowing the resident to reminisce about the past and listening with interest encourages verbalization, gives the resident a feeling of security, and decreases the client's sense of isolation. Involving the resident in interesting diversional activities in a small group discourages verbalization between the resident and the nurse. Reminding the resident that those "good old days" are past and that the focus should be on the present discourages verbalization of feelings and the life review task associated with older adulthood. It is the nurse's, not other residents', role to meet the emotional needs of this resident. Individuals with cognitive impairments are usually unable to facilitate discussion groups.

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

Use ratio and proportion to solve this problem. Desire 5 mg x mL ---------------- = ------- Have 2 mg 1 mL 2x = 5 x = 5 ÷ 2 x = 2.5 mL

hat are the "four A's" for which nurses should evaluate clients with suspected Alzheimer disease? 1. Amnesia, apraxia, agnosia, aphasia 2. Avoidance, aloofness, asocial, asexual 3. Autism, loose association, apathy, affect 4. Aggressive, amoral, ambivalent, attractive

1. Amnesia, apraxia, agnosia, aphasia Neurofibrillary tangles in the hippocampus cause recent memory loss (amnesia); temporoparietal deterioration causes cognitive deficiencies in speech (aphasia), purposeful movements (apraxia), and comprehension of visual, auditory, and other sensations (agnosia). Avoidance, aloofness, asocial, and asexual are characteristics of the schizoid personality. Autism, loose association, apathy, and affect are characteristics of schizophrenia. Aggressive, amoral, ambivalent, and attractive are characteristics of an antisocial personality.

Without knocking, a nurse enters the room of a young male client with the diagnosis of panic disorder and finds him masturbating. What should the nurse do? 1. Apologize and leave the room 2. Tactfully assess why he needs to masturbate 3. In a calm, quiet manner say, "This behavior is inappropriate in the hospital." 4. Pretend not to have seen the masturbation and carry out whatever task needs to be done

1. Apologize and leave the room The client has the right to privacy; his behavior is acceptable in the privacy of his room. Masturbation is a sexual outlet; assessment is unnecessary unless the act is practiced to excess. Pretending not to have seen the client and carrying out whatever task needs to be done may cause needless embarrassment to the client and close off further communication. The behavior is not inappropriate; the client was in the privacy of his own room.

The nurse should suspect that a client who had a recent myocardial infarction is experiencing denial when the client does what? 1. Attempts to minimize the illness 2. Lacks an emotional response to the illness 3. Refuses to discuss the condition with the client's spouse 4. Expresses displeasure with the prescribed activity program

1. Attempts to minimize the illness Attempting to minimize the illness is a classic sign of denial; by reducing the importance or extent of the problem, the individual is able to cope. Not acknowledging that it is really a problem is a form of denial. Lacking an emotional response to the illness indicates repression of affect rather than denial. Failure to communicate is insufficient evidence to diagnose denial; the marital relationship may be strained, or the client may be worried about upsetting the spouse. Expressing displeasure with the activity program usually indicates displacement of anger, not denial.

Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client's health history? 1. Attention span 2. Primary language 3. Coping mechanisms 4. Activity and coordination

1. Attention span Attention span is an intellectual dimension used to gather data for a health history. A social dimension for gathering health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination.

A client is admitted to a psychiatric hospital after a month of unusual behavior that has included eating and sleeping very little, talking and singing constantly, and going on frequent shopping sprees. In the hospital, the client is demanding, bossy, and sarcastic. Which disorder does the nurse associate with these behaviors? 1. Bipolar disorder, manic phase 2. Antisocial personality disorder 3. Obsessive-compulsive disorder 4. Chronic undifferentiated schizophrenia

1. Bipolar disorder, manic phase This kind of hyperactive behavior is typical of the manic flight into reality associated with mood disorders. The behaviors are more indicative of a mood disorder than a personality disorder. Ritualistic, not manic, behavior is indicative of obsessive-compulsive disorder. A flat affect and apathy are more indicative of a schizophrenic disorder.

A resident in a nursing home recently immigrated to the United States from Italy. How does the nurse plan to provide emotional support? 1. By offering choices consistent with the client's heritage 2. By ensuring that the client understands American beliefs 3. By assisting the client in adjusting to the American culture 4. By correcting the client's misconceptions about appropriate health practices

1. By offering choices consistent with the client's heritage Adherence to a plan of care is enhanced by the nurse's providing choices consistent with the client's cultural beliefs and practices. The nurse's cultural or personal beliefs and biases should not influence or interfere with the implementation of appropriate care. Helping the client adjust to the American culture is not the priority at this time; care should be adapted to the client's needs and culture. The person's cultural practices should not be addressed unless they are detrimental to the person's health.

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?" What is the nurse using? 1. Clarifying 2. Structuring 3. Confronting 4. Paraphrasing

1. Clarifying Clarifying is an attempt to better understand the message intended by the client. It is utilized to gain a clearer understanding of what another person has stated. Structuring is an attempt to create order and thereby allow a client to become aware of problems. Confronting examines a discrepancy between what a person is saying and what a person does. It requires careful attention to nonverbal communication, as well as the discrepancies between the nonverbal and verbal message. Paraphrasing allows the speaker to share how one person perceives and hears another's information. The nurse is not paraphrasing but instead is attempting to better understand the client.

A nurse should reassess an older adult client's needs and current plan of care when the client's behavior indicates the development of what symptom? 1. Confusion 2. Hypochondriasis 3. Additional complaints 4. Increased socialization

1. Confusion The development of confusion indicates that the client's ability to maintain equilibrium has not been achieved and that further disequilibrium is occurring. Hypochondriasis and additional complaints do not indicate that the plan needs to be changed unless the client's history demonstrates no prior use of these defenses. Increased socialization is a positive response to the plan of care that does not require reassessment.

An older client with the diagnosis of dementia of the Alzheimer type is admitted to a long-term care facility. What should the nurse keep in mind regarding confusion when planning care for this client? 1. Confusion occurs with a transfer to new surroundings. 2. Confusion will be unchanged despite reality orientation. 3. Confusion is a common finding and is expected with aging. 4. Confusion results from brain changes that make interventions futile.

1. Confusion occurs with a transfer to new surroundings. A change in environment and introduction of unfamiliar stimuli precipitate confusion in clients with dementia-type disorders; with appropriate intervention, including frequent reorientation, confusion can be reduced. Reality orientation can reduce confusion when these clients are confronted with unfamiliar surroundings. The assertions that reality orientation is ineffective, that confusion is an expected finding in aging, and that brain changes in dementia make interventions futile are all untrue.

A 30-year-old woman reports to the mental health clinic on the recommendation of her primary health care provider. She has been unable to carry out everyday activities because of increased pain in her lower back and legs. Numerous neurological and orthopedic workups indicate that her symptoms seem excessive when compared with the physical problems shown on physical examination and repeated MRIs and x-rays. She says that no one understands how difficult it has been to care for her 32-year-old husband, who has an inoperable brain tumor and is undergoing chemotherapy. In light of the history and symptoms, what disorder should the nurse suspect? 1. Conversion 2. Malingering 3. Referred pain 4. Body dysmorphic

1. Conversion Clients with conversion disorder have physical symptoms caused by psychological conflicts and stressors. It is the most common of the somatoform disorders and is initiated or exacerbated by significant psychological stressors. Malingering is a type of manipulation in which false or exaggerated symptoms are used to obtain a specific result, such as avoiding work or jail. Referred pain originates in one area of the body and is experienced (referred) in another part of the body that is not receiving the noxious stimulus directly. Body dysmorphic disorder is when a person believes that his or her body is deformed in some manner that is not readily observed by others.

Which medication may be used to encourage abstinence in a client with alcoholism? 1. Disulfiram 2. Lorazepam 3. Methadone 4. Chlordiazepoxide

1. Disulfiram Rehabilitation helps an alcoholic client abstain from alcohol abuse. Disulfiram is a medication that may be administered to the alcoholic client to encourage abstinence. During detoxification of alcoholic clients, lorazepam and chlordiazepoxide are used to treat tremors, nervousness, and restlessness, but they are not used to promote abstinence. Methadone is a synthetic opioid that helps suppress withdrawal symptoms in clients addicted to morphine or heroin.

Relatives of the victims of a home invasion in which several family members were killed receive crisis intervention services. Which therapy is most beneficial after the immediate event has passed? 1. Grief 2. Family 3. Psychoanalytical 4. Psychoeducational

1. Grief Grief therapy provides guidance as one completes the tasks of successful mourning; its goal is to prevent unresolved and dysfunctional grief. Family therapy focuses on the family as a system rather than on just one individual's problem; the goals of family therapy are to foster the self-worth of all members, promote clear and honest communication among members, create guidelines for interaction that are realistic and flexible, and link individuals and family with society in ways that are open and hopeful. No data in the scenario indicate that the family became dysfunctional after the tragedy. Psychoanalytic therapy is generally not used to explore unresolved grief. Psychoanalysis helps the individual become aware of repressed emotional conflicts, analyze their origin, and, through the process of insight, bring them into consciousness, so maladaptive behavior can be altered. Psychoeducational therapy is focused on teaching clients and family members about disorders, treatments, and resources with the goal of empowering them to participate in their own care once they have the knowledge. No evidence in the scenario indicates that the families need psychoeducational therapy.

A nurse is caring for a young, hyperactive child with attention deficit hyperactivity disorder who engages in self-destructive behavior. What is the most important nursing objective in the planning of care for this child? 1. Keeping the child from inflicting any self-injury 2. Helping the child improve his communication skills 3. Helping the child formulate realistic ego boundaries 4. Providing the child with opportunities to discharge energy

1. Keeping the child from inflicting any self-injury All nursing care should be directed toward preventing injury, particularly with a self-destructive child. Although improved communication skills, formulation of realistic ego boundaries, and opportunities to discharge energy are all important, prevention of injury is the priority.

A nurse is planning to teach a client about self-care. What level of anxiety will best enhance the client's learning abilities? 1. Mild 2. Panic 3. Severe 4. Moderate

1. Mild Mild anxiety motivates one to action, such as learning or making changes. Higher levels of anxiety tend to blur the individual's perceptions and interfere with functioning. Attention is severely reduced by panic. The perceptual field is greatly reduced with severe anxiety and narrowed with moderate anxiety.

A client with major depression that includes psychotic features tells the nurse, "All of my relatives have been killed because I've been sinful and need to be punished." What is the primary focus of nursing interventions? 1. Protecting the client against any suicidal impulses 2. Supporting the client's interest in the outside world 3. Helping the client manage the concern for family members 4. Reassuring the client that past behaviors are not being punished

1. Protecting the client against any suicidal impulses Suicidal impulses take priority, and the client must be stopped from acting on them while treatment is in progress; the client's safety is the focus of nursing interventions. Supporting the client's interest in the outside world is of very low priority. The client is focusing on the current personal situation, not the outside world. Helping the client manage the concern for family members is a secondary concern. Reassurance will not change the client's belief.

A client with the diagnosis of schizophrenia, paranoid type, has been receiving a phenothiazine drug. When the psychiatric daycare center plans a fishing trip, it will be important for the nurse to take which action? 1. Provide the client with sunscreen. 2. Caution the client to limit exertion during the trip. 3. Give the client an extra dose of medication to take after lunch. 4. Take the client's blood pressure before allowing participation in the outing.

1. Provide the client with sunscreen. Phenothiazines commonly cause a photosensitivity that can be controlled with sunscreen. Limiting activity is not a necessary precaution when phenothiazines are prescribed. The medication must be administered as prescribed. Participating in the outing should not negatively affect the client's blood pressure.

A nurse enters the room of an agitated, angry client to administer the prescribed antipsychotic medication. The client shouts, "Get out of here!" What is the nurse's best approach? 1. Say, "I'll be back in 15 minutes, and then we can talk." 2. Get assistance and give the medication by way of injection 3. Explain why it is necessary to comply with the practitioner's order 4. Tell the client, "You have to take the medicine that's been prescribed for you."

1. Say, "I'll be back in 15 minutes, and then we can talk." Saying, "I'll be back in 15 minutes, and then we can talk" allows the agitated, angry client time to regain self-control; telling the client that the nurse will return will decrease possible guilt feelings and implies to the client that the nurse cares enough to come back. Getting assistance and giving the medication by way of injection does not respect the client's feelings; it may decrease trust and increase feelings of anger, helplessness, and hopelessness. An agitated, angry client will not be able to accept a logical explanation. Continued insistence may provoke increased anger and further loss of control.

Which medication is effective in treating eating disorders? 1. Sertraline 2. Clozapine 3. Benztropine 4. Chlorpromazine

1. Sertraline Medications such as sertraline are helpful in treating eating disorders. Clozapine is used in the treatment of resistant forms of schizophrenia. Benztropine is an antiparkinsonian medication. Chlorpromazine is an antipsychotic agent.

A client who has been battling cancer of the ovary for 7 years is admitted to the hospital in a debilitated state. The healthcare provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client's room and finds her crying. Which is the most appropriate intervention by the nurse? 1. Sit down quietly next to the bed and allow her to cry. 2. Pull the curtain and leave the room to provide privacy for the client. 3. Explain to the client that her feelings are expected and they will pass with time. 4. Observe the length of time the client cries and document her difficulty accepting her impending death.

1. Sit down quietly next to the bed and allow her to cry. Sitting down quietly next to the bed and allowing her to cry demonstrates acceptance of the client's behavior and provides an opportunity for the client to verbally express feelings if desired. Pulling the curtain and leaving the room to provide privacy for the client may make the client feel that the behavior is wrong or is annoying others. Also, it abandons the client when support is needed. Explaining to the client that her feelings are expected and they will pass with time closes off communication and does not provide an opportunity for the client to talk about feelings. Also, it provides false reassurance. The length of time she cries is unimportant at this time. Assuming that she is having difficulty accepting her impending death is a conclusion without enough information.

What is the most important tool a nurse brings to the therapeutic nurse-client relationship? 1. The self and a desire to help 2. Knowledge of psychopathology 3. Advanced communication skills 4. Years of experience in psychiatric nursing

1. The self and a desire to help The nurse brings to a therapeutic relationship the understanding of self and basic principles of therapeutic communication; this is the unique aspect of the helping relationship. Knowledge of psychopathology, advanced communication skills, and years of experience in the field all support the psychotherapeutic management model, but none is the most important tool used by the nurse in a therapeutic relationship.

When communicating with a client with a psychiatric diagnosis, the nurse uses silence. How should clients feel when silence is used in therapeutic communication? 1. Unhurried to answer 2. It is their turn to talk 3. The nurse is thinking about the interaction 4. The nurse expects that further communication is unnecessary

1. Unhurried to answer Silence is a tool employed during therapeutic communication that indicates that the nurse is listening and receptive; it allows the client time to collect thoughts, gain control of emotions, or speak without hurrying. Silence should be comfortable and should not create pressure to talk. The client should feel that he or she has an opportunity to think about the interaction. The client's perception that the nurse expects that further communication is unnecessary will close communication.

A client with schizophrenia is started on a regimen of chlorpromazine. After 10 days a shuffling gait, tremors, and some rigidity are apparent. Benztropine mesylate 2 mg by mouth daily is prescribed. What does the nurse remember when administering these medications together? 1. Both medications are cholinesterase inhibitors. 2. Both medications have a cholinergic-blocking action. 3. The antipsychotic effects of chlorpromazine will be decreased. 4. The synergistic effect of these medications will cause drooling.

2. Both medications have a cholinergic-blocking action. Both medications block central acetylcholine receptors. Neither medication inhibits cholinesterase; neostigmine (Prostigmin) acts in this manner. Although benztropine mesylate can cause mental confusion when given in large doses, it does not reduce the antipsychotic effect of chlorpromazine. Both medications cause dry mouth.

Which treatment strategy is beneficial for a client with panic disorder? 1. Milieu therapy 2. Debriefing technique 3. Confrontation therapy 4. Electroconvulsive therapy

2. Debriefing technique The debriefing technique is often used to treat panic disorder. Milieu therapy is used to treat clients with schizophrenia. Confrontation therapy is not generally used to treat mental health disorders. Electroconvulsive therapy is used to treat affective disorders.

A client with cancer is told by a health care provider that the cancer has metastasized to other organs and is untreatable. The client tells the nurse, "I think they made a mistake. I don't think I have cancer. I feel too good to be dying." Which stage of grief does the nurse conclude that the client is experiencing? 1. Anger 2. Denial 3. Bargaining 4. Acceptance

2. Denial The client has difficulty accepting the inevitability of death and attempts to deny the reality of it. In the anger stage the client strikes out with statements such as "Why me?" and "How could God do this to me?" The client is angry at life and is still angrier to be removed from it by death. In the bargaining stage the client attempts to bargain for more time; the reality of death is no longer denied, but the client tries to manipulate and extend the remaining time. In the acceptance stage the client accepts the inevitability of death and quietly awaits it.

What type of disorder is anorexia nervosa? 1. Mood disorder 2. Eating disorder 3. Sexual disorder 4. Thought process disorder

2. Eating disorder The eating disorder anorexia nervosa is a severe form of self-starvation that can result in death. Mania is a mood disorder. Fetishism is a sexual disorder in which an object, usually an article of clothing, is used to achieve arousal. Schizophrenia is a thought process disorder.

The grieving spouse of a client who has just died says to the nurse, "We should have spent more time together. I always felt that my work came first." What should the nurse conclude that the spouse is experiencing? 1. Displaced anger 2. Feelings of guilt 3. Shame for past behavior 4. Ambivalent feelings about the spouse

2. Feelings of guilt The spouse is expressing the typical feelings of guilt associated with the death of a loved one; often there is initial guilt over what might have been. No evidence supports the displaced anger conclusion. The spouse is expressing guilt, not shame. No evidence supports the ambivalent feelings about the spouse conclusion.

An injured child is brought to the emergency department by the parents. While interviewing the parents, the nurse begins to suspect child abuse. Which parental behaviors might support this conclusion? Select all that apply. 1. Demonstrating concern for the injured child 2. Focusing on the child's role in sustaining the injury 3. Changing the story of how the child sustained the injury 4. Asking questions about the injury and the child's prognosis 5. Giving an explanation of how the injury occurred that is not consistent with the injury

2. Focusing on the child's role in sustaining the injury 3. Changing the story of how the child sustained the injury 5. Giving an explanation of how the injury occurred that is not consistent with the injury The child is often made the scapegoat in the situation; the parents blame the child because they have unrealistic expectations of the child. Discrepancies or inconsistencies in the history result from attempts to present a story that is not based in fact. Discrepancies between the parental explanation for the child's injuries and the physical findings or discrepancies in the history that each parent gives are common because the information that is being provided is not based in fact. Abusive parents usually do not ask questions about the injury or prognosis and demonstrate little or no interest in their child's well-being.

Which addictive drug may cause the dependent user to think that he or she has the ability to fly? 1. Cocaine 2. Hallucinogens 3. Amphetamines 4. Opioid analgesics

2. Hallucinogens Hallucinogens affect various parts of the brain, altering perception and thinking; a chronic user of these drugs may think he or she has the ability to fly. Use of the other drugs has other results. Chronic overdose of cocaine may lead to cardiorespiratory distress and seizures. Amphetamines strongly stimulate the central nervous system and may induce hallucinations and paranoia. Acute opioid overdose may cause severe respiratory depression, pinpoint pupils, and stupor or coma.

A married male client with three children has lost his job and states that he feels useless. He is tearful, upset, and embarrassed. What is an appropriate objective of care for this client? 1. Limiting tearfulness 2. Increasing self-esteem 3. Controlling feelings of sadness 4. Promoting acceptance by others

2. Increasing self-esteem The loss of a job can precipitate negative feelings about the self and decrease self-esteem. Feelings should be expressed, not limited; attempting to decrease a client's crying often ends up worsening it. Crying is not necessarily an expression of sadness; other feelings are involved. The focus should be on the client's self-acceptance, not acceptance by others.

A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? Select all that apply. 1. Dementia 2. Multiple losses 3. Declines in health 4. A milestone birthday 5. An injury requiring hospitalization

2. Multiple losses 3. Declines in health Depression in the older adult is most often associated with the loss of family members and friends (e.g., death, relocation) and declines in mobility, health, and income. A decline in health, particularly when associated with a chronic illness, frequently precipitates depression in older adults. Dementia is a cognitive problem. Research does not correlate the onset of depression with a milestone birthday in older adults. A traumatic injury does not precipitate the onset of depression in the older adult as often as does a chronic illness.

What should a nurse who is caring for a hospitalized older client with dementia consider before planning care? 1. Physical contact will increase dependency needs. 2. Routines provide stability for clients with dementia. 3. Regressive behavior should be interrupted immediately. 4. Procedures do not have to be explained to clients with dementia.

2. Routines provide stability for clients with dementia. Rituals and routines in activities of daily living provide a framework and structure for clients with dementia, adding to their sense of safety and security. Touch is a universal message that denotes caring; it can be soothing and will not encourage dependency. Regressive behavior under stress has a calming effect and should be allowed. Care should be explained to all clients; simple declarative statements are usually understood.

Which emotional condition may be apparent in a client with an addiction? 1. Insomnia 2. Social isolation 3. Acute confusion 4. Functional urinary incontinence

2. Social isolation Social isolation is an emotional condition that may be apparent in a client with an addiction. Insomnia, acute confusion, and functional urinary incontinence are physical, not emotional, conditions that may be apparent in clients with addiction.

Which type of caregiver is the most frequent abuser of older adults? 1. Adult child 2. Spouse 3. Family friend 4. Nonrelated professional caregiver

2. Spouse Caregivers are most often the clients' spouses, and spouses are frequently the perpetrators when an older adult is the victim of abuse. A client's adult child, family friend, or nonrelated professional caregiver may perpetrate abuse as well, but this occurs less often.

An executive, busy at work, receives a phone call from a friend relating bad news. The woman makes a conscious effort to put this information out of her mind and continues to work at the task at hand. The next day she remembers that her friend telephoned her but is unable to recall the message. Which defense mechanism does this behavior represent? 1. Regression 2. Suppression 3. Passive aggression 4. Reaction formation

2. Suppression Suppression is the voluntary exclusion from awareness of anxiety-producing feelings, ideas, and situations. In regression, a person returns to an earlier and more comfortable developmental level. Passive aggression is the use of behaviors such as passivity, procrastination, and inefficiency that negatively affect others. Reaction formation is a conscious behavior that is the opposite of an unconscious feeling.

A client who is dying jokes about the situation even though the client is becoming sicker and weaker. Which is the most therapeutic response by the nurse? 1. "Why are you always laughing?" 2. "Your laughter is a cover for your fear." 3. "Does it help to joke about your illness?" 4. "The person who laughs on the outside cries on the inside."

3. "Does it help to joke about your illness?" The response "Does it help to joke about your illness?" is a nonjudgmental way to point out the client's behavior. The response "Why are you always laughing?" is too confrontational; the client may not be able to answer the question. The response "Your laughter is a cover for your fear" is too confrontational and an assumption by the nurse. The response "The person who laughs on the outside cries on the inside" is too judgmental, an assumption, and a stereotypical response.

Which statement about addiction needs correction? 1. Alcoholism is an example of addiction. 2. Addiction is excessive use or abuse of a substance. 3. A person can have only a single addiction at one time. 4. Addiction can be characterized by a display of psychological disturbance

3. A person can have only a single addiction at one time. A person can have more than one addiction at the same time. The other statements are correct: Alcoholism is an example of addiction. Addiction is excessive use or abuse of a substance, and it can be characterized by a display of psychological disturbance.

Many people control anxiety with the use of ritualistic behavior. What must the nurse do when caring for these clients? 1. Avoid mentioning the ritual 2. Explain the meaning of the ritual 3. Allow them time to carry out the ritual 4. Prevent them from carrying out the ritual

3. Allow them time to carry out the ritual Allowing the client who uses a ritual time to carry out the ritual reduces the client's anxiety. Clients prevented from using ritualistic behavior to control anxiety are being deprived of a defense and will not be able to relieve tension. The client's behavior should never be ignored; it is important to accept and support these clients during this time. Explaining the meaning of the ritual will not decrease the use of the behavior. Preventing a ritualistic behavior will probably increase the client's anxiety.

Two 20-year-old female clients on the psychiatric unit have become very much attached to each other and are found in bed together. They become angry and sarcastic when the nurse asks one of them to return to her own bed. How can the nurse best address this situation? 1. By asking the health care provider to transfer one of the clients to another unit 2. By limiting their privileges for several days because their behavior is undesirable 3. By adopting a matter-of-fact, nonjudgmental attitude and setting limits on the behavior 4. By supervising them carefully and separating them when possible throughout the day and always at night

3. By adopting a matter-of-fact, nonjudgmental attitude and setting limits on the behavior Everyone has the right to his or her sexual orientation and preferences, but limits must be set on acting-out behavior on a psychiatric unit. Helping clients deal with their sexuality in a more appropriate manner is more therapeutic than continuous separation by the staff. Punishment is inappropriate.

A client in the mental health clinic tells the nurse, "The FBI is out to kill me." What should the nurse document that the client is experiencing? 1. Hallucination 2. Error in judgment 3. Delusion of persecution 4. Self-accusatory delusion

3. Delusion of persecution A delusion of persecution is a fixed and firm belief or a feeling of being harassed, in danger, or at the mercy of others. Hallucinations are perceived experiences that occur in the absence of actual sensory stimulation. An error in judgment is poor decision-making, not a distortion of reality like a delusion. In a self-accusatory delusion the person accepts blame for an act that never was committed.

The parents of an overweight adolescent girl tell the nurse that they are concerned that their daughter feels inferior to her sister, who is an attractive, successful college senior. They ask the nurse what they can do about this problem. What should the nurse do? 1. Suggest that they appear to be creating a problem where none exists 2. Tell them to avoid talking about their older child's accomplishments 3. Encourage the parents to give the adolescent recognition for her strong points 4. Advise the parents to tell the adolescent to view her sister's success as a challenge

3. Encourage the parents to give the adolescent recognition for her strong points Encouraging the parents to give the adolescent recognition for her strong points will help the parents foster improved self-esteem in the younger daughter. A problem does exist; their child is overeating. The parents cannot avoid talking about the sibling, but they should avoid any comparisons. The child already is viewing the sister's success as a challenge, and it has diminished her self-esteem.

A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the preceding month. Of which level of suicidal behavior is the client's behavior reflective? 1. Threats 2. Ideation 3. Gestures 4. Attempts

3. Gestures A suicidal gesture involves superficial, nonlethal injuries; the client has no intent to die as a result of the injuries. A suicidal threat is a person's verbal statement of intent to commit suicide; there is no action. Suicidal ideation is a person's thoughts regarding suicide; there is no definitive intent or action expressed. A suicide attempt is an actual implementation of a severe self-injurious act; there is an attempt to cause serious self-harm or death.

A client is admitted to a psychiatric hospital with the diagnosis of schizoid personality disorder. Which initial nursing intervention is a priority for this client? 1. Helping the client enter into group recreational activities 2. Convincing the client that the hospital staff is trying to help 3. Helping the client learn to trust the staff through selected experiences 4. Arranging the client's contact with others so it is limited while she is in the hospital

3. Helping the client learn to trust the staff through selected experiences Demonstrating that the staff can be trusted is a vital initial step in the therapy program. The client is not ready to enter group activities yet and will not be until trust is established. Even proof will not convince the client with a schizoid personality that feelings of distrust are false. Arranging the client's contact with others is not realistic even if it is possible; limiting contact with other clients will not enhance trust.

An older adult is brought to the clinic by a family member because of increasing confusion over the past week. What can the nurse ask the client to do to determine orientation to place? 1. Explain a proverb 2. Give the state where he or she was born 3. Identify the name of the clinic's town 4. Recall what he or she ate for breakfast

3. Identify the name of the clinic's town Orientation to place refers to an individual's awareness of the objective world in its relation to the self; orientation to time, place, and person is part of the assessment of cerebral functioning. Explaining a proverb requires abstract thinking, which involves a higher integrative function than does orientation to place. Having the client state where he or she was born helps the nurse assess remote memory, not orientation. Having the client recalling what he or she had for breakfast helps assess recent memory, not orientation.

At night an older client with dementia sleeps very little and becomes more disoriented. How can the nurse best limit this confusion resulting from sleep deprivation? 1. Shutting the client's door during the night 2. Applying a vest restraint when the client is in bed 3. Leaving a dim light on in the client's room at night 4. Administering the client's prescribed as-needed sedative medication

3. Leaving a dim light on in the client's room at night A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment. A disoriented and confused client should be closely observed, not isolated. Restraints are a last resort; less restrictive interventions should be used first. Sedatives should be used sparingly in older adults, because they may cause further confusion and agitation.

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? 1. Confronting the client about the behavior 2. Turning on the television to distract the client 3. Maintaining a calm, consistent approach with the client 4. Explaining to the client why the behavior is unacceptable

3. Maintaining a calm, consistent approach with the client Consistency ensures an approach that is known and less frightening than the unknown. A calming approach can decrease agitation. Confronting the client about the behavior may escalate the client's anger and agitation. Environmental stimulants should be decreased, not increased. An agitated client is not capable of comprehending logical explanations; the nurse must avoid criticisms and arguments with the client.

A health care provider prescribes divalproex (Depakote). What does the nurse consider an appropriate indication for the use of this drug? 1. Control of acute agitation of schizophrenia 2. Treatment of the agitated phase of a paranoid state 3. Management of manic episodes of bipolar disorder 4. Modification of the depressive phase of major depression

3. Management of manic episodes of bipolar disorder Although divalproex (Depakote) is an antiepileptic, it is used to control the manic phase of a bipolar disorder. Divalproex is not the drug of choice for schizophrenia; nor is it used for agitated paranoid states. Divalproex is not used for major depression, except with a history of at least one manic episode or a family history of manic disorders.

Which tool is used to standardize and measure nursing treatments? 1. Nursing Outcomes Classification (NOC) 2. NANDA-I Approved Nursing Diagnoses 3. Nursing Interventions Classification (NIC) 4. Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

3. Nursing Interventions Classification (NIC) Nursing Interventions Classification (NIC) is a tool that helps to define nursing interventions, as well as helps to standardize and measure the nursing care provided. Nursing Outcomes Classification (NOC) helps measure the outcome of the nursing interventions implemented to the patient. NANDA-I Approved Nursing Diagnoses are used to identify and describe the patient needs, serving as a basis for planning care. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is a guidebook for diagnostic and treatment codes for mental disorders.

A nurse understands that when a client is a member of a different ethnic community it is important to do what? 1. Ensure that the nurse's biases are understood by the family 2. Make plans to counteract the client's misconceptions about therapies 3. Offer a therapeutic regimen compatible with the lifestyle of the family 4. Recognize that the client's responses will be similar to other clients' responses

3. Offer a therapeutic regimen compatible with the lifestyle of the family The client cannot be expected to accept or even respond to a plan that is incompatible with the family's lifestyle. The family should not have to adjust to the nurse's biases; the nurse must self-identify biases and ensure that they do not interfere with nursing care. There is no evidence that misconceptions will occur. All individuals respond differently to situations.

An older adult client is talking to the nurse about his Vietnam experiences and shares that he still has flashbacks. While assessing him the nurse notes that he is jumpy and exhibits startle reactions and poor concentration. With which mental health disorder does the nurse associate these symptoms? 1. Delusions 2. Hallucinations 3. Posttraumatic stress disorder (PTSD) 4. Obsessive-compulsive disorder (OCD)

3. Posttraumatic stress disorder (PTSD) PTSD is a syndrome characterized by the development of symptoms after an extremely traumatic event. Symptoms include helplessness, flashbacks, intrusive thoughts, memories, images, emotional numbing, loss of interest, avoidance of any place that reminds the affected person of the traumatic event, poor concentration, irritability, startle reactions, jumpiness, and hypervigilance. Delusions are beliefs that guide one's interpretation of events and help make sense of disorder. Common delusions among older adults involve being poisoned, having their assets taken by their children, being held prisoner, and being deceived by a spouse or lover. Hallucinations are visual or auditory perceptions of nonexistent objects and sounds. Older adults with hearing and vision deficits may hear voices or see people who are not actually present. OCD is characterized by recurrent and persistent thoughts, impulses, and urges of ritualistic behaviors that improve the affected person's comfort level.

Which therapy is long-term and intense and enables a client to bring unconscious thoughts to the surface? 1. Hypnosis 2. Play therapy 3. Psychoanalysis 4. Cognitive therapy

3. Psychoanalysis Psychoanalysis is an intense long-term form of therapy that enables a client to bring unconscious thoughts to the surface. Hypnosis helps a client recover deeply repressed emotions. Play therapy helps children express themselves with the use of toys such as puppets as their "spokespeople" for feelings. Cognitive therapy is focused on breaking negative thought patterns and developing positive feelings about memories or thoughts.

A 10-year-old child in whom autism was diagnosed at the age of 3 attends a school for developmentally disabled children and lives with his parents. The child has frequent episodes of self-biting and head-banging and needs help with feeding and toileting. What is the priority nursing goal for this child? 1. Controlling repetitive behaviors 2. Being able to feed independently 3. Remaining safe from self-inflicted injury 4. Developing control of urinary elimination

3. Remaining safe from self-inflicted injury The priority is safety; the child must be protected from self-harm. Repetitive behaviors are comforting, and unless they are harmful their limitation is not a priority. Although feeding independently is a basic need that may be achieved, it is not the priority. Children who need help with toileting are not necessarily incontinent, and it is not the priority.

A client with schizophrenia is taking benztropine (Cogentin) in conjunction with an antipsychotic. The client tells a nurse, "Sometimes I forget to take the Cogentin." What should the nurse teach the client to do if this happens again? 1. Take 2 pills at the next regularly scheduled dose. 2. Notify the health care provider about the missed dose immediately. 3. Take a dose as soon as possible, up to 2 hours before the next dose. 4. Skip the dose, then take the next regularly scheduled dose 2 hours early.

3. Take a dose as soon as possible, up to 2 hours before the next dose. Taking a dose as soon as possible is the advised intervention when a dose is missed; interruption of the medication may precipitate signs of withdrawal such as anxiety and tachycardia. Taking 2 pills at the next regularly scheduled dose will provide an excessive amount of the medication at one time. Notifying the health care provider about the missed dose immediately is unnecessary. Skipping a dose is not advised if the next regularly scheduled dose is due within 2 hours.

A client who consented to electroconvulsive therapy (ECT) is being prepared for the second session. The client tells the nurse, "I've decided that I don't want this treatment." What is the best response by the nurse? 1. "It's too late to stop the treatment now." 2. "We'll discuss the advantages after the treatment." 3. "You need more than one treatment for it to be successful." 4. "I'll tell your psychiatrist that you don't want the treatment."

4. "I'll tell your psychiatrist that you don't want the treatment." A client has the right to revoke consent for treatment at any time; continuing treatment is a violation of the client's rights. "It's too late to stop the treatment now" is incorrect, and continuing with the treatment would be an act of battery. Teaching about the advantages and disadvantages of therapy should be conducted before, not after, the treatment; giving the client treatment without consent is an act of battery. A statement such as "You need more than one treatment for it to be successful" is considered coercion; continuation of treatment after the client's refusal would be an act of battery.

A client with generalized anxiety disorder says to the nurse, "What can I do to keep myself from overreacting to stress?" What is the best response by the nurse? 1. "Work on developing more positive relationships." 2."Improve your time-management skills." 3. "Ignore situations that you cannot change." 4. "Work on identifying and developing coping strategies."

4. "Work on identifying and developing coping strategies." Identifying and developing a wide variety of coping strategies increases the individual's ability to cope with stress; different defenses can be used in various situations. Developing positive relationships may help the patient, but this is not the most significant step the patient can take to address stressful situations. Improved time-management skills may or may not be helpful. People should not ignore situations that affect them.

A male client with the diagnosis of antisocial personality disorder takes a female nurse by the shoulders, kisses her, and shouts, "I like you." What is the most appropriate response by the nurse? 1. "Thank you. I like you, too." 2. "I wish you wouldn't do that." 3. "Don't ever touch me like that again. I don't like it" 4. "Your behavior is inappropriate. Don't do that again."

4. "Your behavior is inappropriate. Don't do that again." Telling the client that his behavior is inappropriate and instructing him not to do it again accepts the client while rejecting and setting limits on the behavior the client is using. Thanking the client and telling him that she likes him, too, encourages this type of behavior instead of setting limits. Saying that she wishes the client wouldn't do that or telling the client not to touch her like that again and that she doesn't like it makes it appear that it is the nurse's preference, not the client's behavior, that is the issue.

A nurse tells the family member of an alcoholic client, "This condition occurs in individuals who have developed physiologic dependence on alcohol and then quit drinking abruptly." To which condition is the nurse referring? 1. Korsakoff psychosis 2. Fetal alcohol syndrome 3. Wernicke encephalopathy 4. Alcohol withdrawal syndrome

4. Alcohol withdrawal syndrome Alcohol withdrawal syndrome occurs in individuals who have developed a physiologic dependence on alcohol and then quit drinking abruptly. Korsakoff psychosis and Wernicke encephalopathy are brain disorders; they may occur in clients with chronic alcoholism. Fetal alcohol syndrome is a congenital anomaly that results from maternal use of alcohol during pregnancy. These conditions are not associated with abrupt cessation of alcohol use.

A client who has been admitted to the hospital for an elective prostatectomy is extremely anxious and has hand tremors. The client's partner informs the nurse that the client has been drinking heavily for the past 5 years. While the client is unpacking his items from home, the nurse sees him hiding a bottle of whiskey in the rear of a drawer. How should the nurse respond initially to this behavior? 1. Try to catch the client drinking the alcohol 2. Confiscate the alcohol when the client is not looking 3. Wait for the client to bring up the subject of drinking 4. Ask the client how much alcohol he consumes in a week

4. Ask the client how much alcohol he consumes in a week Asking the client how much alcohol he consumes in a week will reveal the client's level of alcohol abuse through direct questioning and will open the way to a conversation about the importance of not drinking during his hospital stay. Trying to catch the client drinking the alcohol is a judgmental approach that involves manipulation and will decrease the client's self-esteem. Confiscating the alcohol when the client is not looking is not straightforward and will decrease trust. The client probably will not bring up the subject, because denial is often used to cope with alcohol abuse.

A 6-year-old child recently started school but has been refusing to go for the past 3 weeks. What does the nurse determine is an appropriate intervention for this child? 1. Explain that school is a place to have fun 2. Delay the return to school for several months 3. Enroll the child in a special education program 4. Develop a behavior modification program with the child

4. Develop a behavior modification program with the child A behavior modification program tailored for and developed with the individual child is the most appropriate approach at this time. School may or may not be a place to have fun. The child may not like school and may not think that it is fun, but having fun is not the purpose of school. Delaying the child's return to school for several months serves no purpose and may be viewed by the child as a reward for the behavior. There are no data to indicate that the child is in need of special education.

What is the nurse's specific responsibility when the rights of a client on a mental health unit are restricted by the use of seclusion? 1. Informing the client's family 2. Monitoring pharmacological interventions 3. Completing a denial-of-rights form and forwarding it to the administrative officer 4. Documenting both the client's behavior and the reason that specific rights were denied

4. Documenting both the client's behavior and the reason that specific rights were denied Seclusion and restraints are special procedures for dealing with aggressive acting-out behavior for the protection of the client and others; clear documentation is essential when the client's rights are restricted. Informing the client's family is not necessary because the use of seclusion or restraints is included in the general consent form that is signed on admission. Pharmacological intervention should be monitored for all clients. There is not a typical form; however, documentation is required to justify the need for seclusion or the use of restraints.

A nurse is assessing a middle-aged client whose children have left home in search of work. The client is trying to adjust to these family changes. Which family life-cycle stage is the client going through? 1. Family in later life 2. Family with adolescents 3. Unattached young adult 4. Launching children and moving on

4. Launching children and moving on The client is adjusting to a reduction in family size after the adult children have left home in search of work. The client is going through the launching children and moving on stage of the family life-cycle stage. An individual going through the family in later life stage deals with retirement and the loss of a spouse, siblings, or other peers. The family in the adolescents stage of the family lifecycle involves establishing flexible boundaries to accommodate the growing child's independence. An individual experiencing the unattached young adult stage begins to differentiate themselves from his or her family of origin. The young adult establishes him or herself at work while the young adult's parents experience the launching children and moving on stage.