hesi psych FULL

The nurse is attempting to communicate with a client newly admitted with Alzheimer's disease. What actions will the nurse include in the client's plan of care? (Select all that apply.) A. Maintain eye contact when talking with the client. B. Shout directly at the client at all times. C. Call the client by name with each new interaction. D. Use many different words to express the same thought. E. Give multiple directions at the same time.

. A. Maintain eye contact when talking with the client. C. Call the client by name with each new interaction. Rationale: Use a calm and firm tone of voice when talking to the client. Do not rephrase, as that can be additionally confusing for the client. Give simple directions, one at a time. The nurse should always call the client by name as well as self-identify when interacting with the client.

Which activities will the nurse include in the care plan for the client admitted with depression? (Select all that apply.) A. Coloring alone in the dayroom B. Low aerobic exercise class with others C. Walking the unit with an aide D. Watching a movie with others E. Making snack mix with one other client

. B. Low aerobic exercise class with others C. Walking the unit with an aide E. Making snack mix with one other client Rationale: The goal is to get the depressed client to use some energy in a positive way, without overwhelming the client. Coloring alone is a low energy, solitary activity. While this may be preferred by the client, it does nothing to slowly engage the client with others. Watching a movie is generally a quiet action. Engaging in discussion afterward may help the client, but that is not a stated option. Making snack mix is nonthreatening and engages the client with one other on the unit. This activity slowly engages the client.

Over a period of several weeks, one participant of a socialization group at a community daycare center for older adults monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation? A. Talk to the client outside the group about his behavior. B. Ask the client to give others a chance to talk. C. Allow the group to handle the problem. D. Ask the client to join another group.

. C. Allow the group to handle the problem. Rationale: After several weeks, the group is in the working phase, and the group members should be allowed to determine the direction of the group. The nurse should ignore the comments and allow the group to handle the situation. A good leader should not have separate meetings with group members, because such behavior is manipulative on the part of the leader. Option B is dictatorial and is not in keeping with good leadership skills. Option D is avoiding the problem. Remember, identify which phase the group is in (initial, working, or termination) as an aid to determining expected communication style.

A client believes that the health care provider is an FBI agent and that the agent's apartment is a site for slave trading. The client believes that the FBI has cameras in the apartment, so it is not safe to return there. Based on these symptoms, which class of medication is most likely to be prescribed for this client? A. Antianxiety medication B. Mood stabilizer C. Antipsychotic D. Sedative-hypnotic

. C. Antipsychotic Rationale: An antipsychotic will most likely be prescribed because the client's thoughts are delusional. The client needs an antipsychotic medication to promote rational thoughts. Option A may lessen anxiety associated with the delusions, but is not the treatment of choice for altered thoughts. Option B will manage mood swings, and Option D will be prescribed for sleep.

Which actions leads the nurse to assess the client is in a manic phase? (Select all that apply.) A. The client sits quietly. B. The client wears a business suit. C. The client is quickly angered. D. The client states, "I am so very hungry." E. A flight of ideas is displayed by the client.

. C. The client is quickly angered. E. A flight of ideas is displayed by the client. Rationale: The client in the manic phase is quick to anger and often displays a flight of ideas. The client cannot sit quietly, and often wears loud and colorful clothing. There is a decrease in appetite for the client in a manic phase.

The emergency department nurse is assigned to a client with a blood alcohol level of 0.14%. What questions will the nurse include in the assessment? (Select all that apply.) A. "How much alcohol have you consumed today?" B. "When did you last consume alcohol?" C. "How long have you been drinking alcohol?" D. "Did you know you are just below the legal limit for our State?" E. "What were you thinking when you drank that much?"

A. "How much alcohol have you consumed today?" B. "When did you last consume alcohol?" C. "How long have you been drinking alcohol?" Rationale: There are basic questions to ask when treating a client with alcohol consumption. They are how much, what type, for how long and when last consumed. The legal limit is generally around 0.08%, but may differ from state to state. 0.14% is clearly over the limit for any state. What were you thinking is a nontherapeutic blame statement.

Based on the premise that those with like experiences can help each other, which groups will the nurse select for referral for clients with similar circumstances? (Select all that apply.) A. Alcoholics anonymous B. Codependents anonymous C. Gamblers anonymous D. Overeaters anonymous E. Debtors anonymous

A. Alcoholics anonymous B. Codependents anonymous C. Gamblers anonymous D. Overeaters anonymous E. Debtors anonymous

The nurse is reviewing techniques of therapeutic communication with a student nurse. Which of the student's statements will the nurse indicate as therapeutic? (Select all that apply.) A. "Am I correct in restating that you are feeling less anxious today?" B. "In looking back at what you said, you stated you are feeling better." C. "Why do you think you are feeling better today?" D. "Surely you did not mean that you are feeling better today." E. "Help me understand what you are feeling today?"

A. "Am I correct in restating that you are feeling less anxious today?" B. "In looking back at what you said, you stated you are feeling better." . E. "Help me understand what you are feeling today?" Rationale: Therapeutic techniques include restating (option A), reflecting (option B), and clarifying (option E). Asking why places the client on the defensive. Surely you did not mean.... Is argumentative.

A client on the behavioral health states, "I hear angles singing. They are calling me home." What is the nurse's best statement in response to this hallucination? A. "Are you thinking of hurting yourself so you can join the angles?" B. "I do not hear angles. It is mealtime; please take a seat at the table." C. "Where are the angles that you hear singing?" D. "While you hear angles, I do not hear anything."

A. "Are you thinking of hurting yourself so you can join the angles? Rationale: The primary nursing responsibility is to keep the client safe from self-harm. Do not attempt to correct the client who is having hallucinations, nor should the nurse play into the hallucination. The priority is safety, then the nurse can help the client orient to reality.

A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad. No one can help me." What is the nurse's best response? A. "How can I help you? Tell me more about your problems." B. "Things probably aren't as bad as they seem right now." C. "Let's talk about what is right with your life." D. "I hear your misery, but things will get better soon."

A. "How can I help you? Tell me more about your problems." Rationale :Offering self shows empathy and caring and gives the client the opportunity to talk while the nurse listens. Option B dismisses the client's perception that things are really bad and potentially stops further communication with the client. Option C avoids the client's problems and promotes denial. "I hear your misery" is an example of reflective dialogue and would be the best choice if it were not for the rest of the sentence, "but things will get better soon," which offers false reassurance.

A 38-year-old client is admitted with a diagnosis of paranoid schizophrenia. When the lunch tray is brought to the room, the client refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response by the nurse is the most therapeutic? A. "I'll leave your tray here. I am available if you need anything else." B. "You're not being poisoned. Why do you think someone is trying to poison you?" C. "No one on this unit has ever died from poisoning. You're safe here." D. "I will talk to your health care provider about the possibility of changing your diet."

A. "I'll leave your tray here. I am available if you need anything else." Rationale: Option A is the best choice because the nurse does not argue with the client or demand that the client eat but offers support by agreeing to be there if needed, which provides an open, rather than closed, response to the client's statement. Options B and C are challenging the client's delusions, and option B asks "why." Probing questions, which start with "why," are usually not therapeutic communication for a psychotic client. Option D has not addressed the actual problem—that is, the client's delusions.

The clinic nurse suspects a new client is suffering from posttraumatic stress disorder. Which assessments will the nurse include in the client's plan of care? (Select all that apply.) A. Anxiety B. Sleep disturbances C. Urinary frequency D. Ritualistic behaviors E. Flashbacks of stressful event

A. Anxiety B. Sleep disturbances E. Flashbacks of stressful event Rationale: Urinary frequency and ritualistic behaviors are commonly not associated with PTSD. Those with PTSD often present with emotional numbness, detachment, depression, anxiety, sleep pattern disturbances, flashbacks, hypervigilance, survivor's guilt, and poor concentration.

A 34-year-old client presents to the clinic with a 4 month old for routine well-baby care. The client is a long-term patient in the clinic, and the child has not been seen there before. Upon review of the client's chart, no pregnancy was ever confirmed or treated in the past. What are the nurse's best actions? (Select all that apply.) A. Ask a coworker to alert the authorities for a potential child abduction. B. Stay with the client and reassure her that, "Everything will be all right." C. Perform routine care for the infant. D. Ask, "Is that the baby who was abducted from the newborn nursery last week?" E. Remain in the examination room and play with the newborn.

A. Ask a coworker to alert the authorities for a potential child abduction. C. Perform routine care for the infant. E. Remain in the examination room and play with the newborn. Rationale: In this potential abduction situation, the nurse must not offer false reassurance that everything will be all right. Confronting the client will break the trust between the nurse and the client. That is an assessment for the authorities who have the necessary training for this situation. The infant still needs routine care. The nurse must stay with the client to assure the infants safety.

Which actions will the nurse take for the client in a depressive phase? (Select all that apply.) A. Ask the client, "Are you thinking of harming yourself?" B. Encourage the client to take part in a game of dodgeball. C. Have the client sit in the day area and fill cups with bird feed. D. Encourage the client to take frequent rest periods. E. Stay with the client when performing daily hygiene and mouth care.

A. Ask the client, "Are you thinking of harming yourself?" C. Have the client sit in the day area and fill cups with bird feed. D. Encourage the client to take frequent rest periods. E. Stay with the client when performing daily hygiene and mouth care. Rationale: The client in a depressive phase has little energy, and needs constant prompting and reassurance. A game of dodgeball uses too much of the client's energy and competitive games need to be avoided. It is important to know if the client wishes self-harm. Filling cups with bird feed is a low energy but satisfying task. Resting is important for those in a depressive phase. The client may not take the usual care in personal hygiene and need the assistance of the nurse to accomplish those tasks.

The nurse is assigned to a client admitted with paranoia. Which actions will the nurse include in the client's plan of care? (Select all that apply.) A. Assess for suicide risk. B. Offer lots of hugs to reassure the client. C. Plan to care for the client when on duty. D. Whisper in the presence of the client. E. Provide a nonthreatening environment.

A. Assess for suicide risk. C. Plan to care for the client when on duty. E. Provide a nonthreatening environment. Rationale: Limit physical contact and do not whisper around the client. This client is at risk for self-harm. Continuity of care is important for the paranoid client. A nonthreatening environment helps establish trust.

Which actions will the nurse take for the client admitted with mania? (Select all that apply.) A. Assign the client to a private room. B. Have the client to play a card game with others on the unit. C. Include the client in preparation of a solitary afternoon craft. D. Assist the client with sweeping the floor of the unit. E. Provide the client with a chicken leg and carrot sticks.

A. Assign the client to a private room. D. Assist the client with sweeping the floor of the unit. E. Provide the client with a chicken leg and carrot sticks Rationale: The client with mania has energy and it needs to be used in a productive manner. A card game is likely to produce a disruption with others on the unit. The client has significant energy and a craft is not likely to use enough of the client's energy. A private room will decrease the interruptions to the roommate. Use the energy of the client in productive activities. The nutritional needs of the client with mania need to be met with hand-held nutritious foods.

The nurse is conducting a small group of overeaters anonymous. What characteristics will the nurse assess for in these clients? (Select all that apply.) A. Binge overeating occurs without purging. B. Eating makes the clients feel powerful. C. Clients are unaware that eating patterns are abnormal. D. Eating often occurs when others are around. E. The clients report feelings of helplessness about their weight.

A. Binge overeating occurs without purging. E. The clients report feelings of helplessness about their weigh Rationale: Overeating makes the clients feel depressed and they often overeat secretly. They are aware that their eating patterns are abnormal, but feel helpless to do anything about their eating habits. The remaining are true about overeaters.

The nurse is working with family members of a client with advanced Alzheimer's disease. What client behaviors will the nurse include in the discussion with the family? (Select all that apply.) A. Difficulty walking independently B. Inability to eat independently C. Switching days and nights D. Bowel and urinary incontinence E. Unaware if surroundings

A. Difficulty walking independently B. Inability to eat independently C. Switching days and nights D. Bowel and urinary incontinence E. Unaware if surroundings Rationale: Along with these symptoms, the client with advanced Alzheimer's disease may catch infections easily, have difficulty communicating and swallowing, will require help with all activities of daily living, may exhibit personality changes such as anxiety, hostility of uncooperativeness, be socially withdrawn, and display sexually inappropriate behavior.

A client who has been hospitalized for 2 weeks for paranoia reports continuously to the staff that some clothing is missing from the closet. What is the correct action for the nurse to take based on the client's complaints? A. Enroll the client in an exercise class to promote positive activities. B. Place a lock on the client's closet to allay the client's concerns. C. Promote extinction of the ideation by ignoring the client. D. Explain to the client that these suspicions are certainly false.

A. Enroll the client in an exercise class to promote positive activities. Rationale: Diverting the client's attention from paranoid ideation and encouraging the client to engage in positive activities can be helpful in assisting to develop a positive self-image. Option B actually supports paranoid ideation. Option C may lower self-esteem. The nurse should not argue with the client about the delusions (option D).

A colleague of an inpatient client on a behavioral unit approaches a nurse and asks, "How is my friend doing?" What is the nurse's best response to the colleague? (Select all that apply.) A. "I appreciate you asking, but I cannot share that information." B. "I can let your colleague know about your inquiry." C. "It is best to reach out to your colleague yourself." D. "Your colleague is doing well, and discharge is expected soon." E. "You will not recognize your colleague; drug rehab has done wonders."

A. I appreciate you asking, but I cannot share that information." C. It is best to reach out to your colleague yourself." Rationale: The nurse cannot disclose any information about the colleague. The nurse needs to guide the colleague to make direct inquiries. If the nurse "lets the colleague know of the inquiry," that nurse just disclosed the patient's inpatient status.

The nurse convenes a new group of clients who were in an abusive relationship. Which client statements does the nurse assess as appropriate for the first meeting? (Select all that apply.) A. "I work at a local car dealership." B. "I have forgiven my spouse for the abuse." C. "I have three children that live with me fulltime." D. "I attend worship services at the community church." E. "One of my children screams out in fear for my life every night."

A. I work at a local car dealership." C. "I have three children that live with me fulltime." D. "I attend worship services at the community church." Rationale: This group is just forming and the conversation will be superficial as the participants get to know and trust one another. Forgiving one's spouse and sharing the experiences of children are statements that demonstrate a trusting relationship, which has not been yet established among the group members.

he nurse is assessing a young client admitted to the psychiatric unit for acute depression related to a recent divorce. Which statement is most indicative of a client suffering from depression? A. "I'm not very pretty or likeable." B. "I've lost 20 pounds in the past month." C. "I like to keep things to myself." D. "I think everyone is out to get me."

A. I'm not very pretty or likeable." Rationale: Feelings of hopelessness are characteristics of one who is depressed. Although option B might be indicative of depression, further assessment would be required to rule out an organic cause before attributing the statement to depression. Options C and D are indicative of a paranoid personality.

Which topics should the nurse include in an education program for clients with schizophrenia and their families? (Select all that apply.) A. Importance of adherence to medication regimen B. Current treatment measures for substance abuse C. Signs and symptoms of an exacerbation D. Prevention of criminal activity E. Behavior modification for aggression F. Chronic grief associated with long-term illness

A. Importance of adherence to medication regimen C. Signs and symptoms of an exacerbation F. Chronic grief associated with long-term illness Rationale: Medication adherence is an important component of successful rehabilitation (A). Clients and their families also need to know the signs and symptoms of an exacerbation or relapse of the disease (C), which is frequently associated with poor medication compliance. Acknowledging the chronic sorrow associated with severe and persistent mental illness (F) helps individuals negotiate the grieving process. (B, D, and E) are not universal problems associated with schizophrenia.

The nurse is caring for a client who is taking valproic acid. Which laboratory finding is most important to include in this client's record? A. Liver function test results B. Creatinine clearance C. Complete blood count D. Chemistry panel

A. Liver function test results Rationale: Valproic acid is metabolized by the liver and can cause hepatotoxicity, so laboratory findings of liver function tests should be included in the client's record. Option B should be in the client record of those who are receiving lithium because it is excreted by the kidneys. Options C and D are routine laboratory tests and are not specifically related to administration of valproic acid.

A unit employee receives a blow to the face when attempting to deescalate a client on the behavioral health unit. Physical restraints are placed on the client, and then the client is put into a seclusion room. What actions must the nurse take in the next hour? (Select all that apply.) A. Meet the physical needs of the client. B. Obtain a prescription for the restraints. C. Objectively document the client's behaviors. D. Tell the other clients on the unit of the events. E. Keep the clients on the unit in their bedroom.

A. Meet the physical needs of the client. B. Obtain a prescription for the restraints. C. Objectively document the client's behaviors. Rationale: Physical aggression on a unit is often chaotic. There is no need to feed into the chaos by retelling the course of events. If others did not witness the event, the nurse needs to protect the privacy of the client. Once the client is in a secure place, there is no need for the other residents of the unit to stay in their bedroom. The source of harm has been removed. The remaining actions are appropriate for this situation.

When planning care for the client undergoing electroconvulsive therapy (ECT), which equipment should the nurse make available? (Select all that apply.) A. Oxygen B. Suction equipment C. Continuous passive range-of-motion (CPM) machine D. Crash cart E. Chest tube drainage system

A. Oxygen B. Suction equipment D. Crash cart Rationale: Because aspiration is a potential complication, emergency equipment such as oxygen, suction, and a crash cart should be available (A, B, and D). The client is only unconscious for a short period; therefore, there is no need for a CPM machine (C). ECT does not put the client at risk for a pneumothorax; therefore, a chest tube drainage system is not needed (E).

For the client with an altered thought process, what will the nurse include in the client's plan of care? (Select all that apply.) A. Place items from home in the client's room. B. Place a calendar on the wall across from the client's bed. C. Place a clock on the client's bedside table. D. Establish a different waking pattern every day. E. Call the client by a new name, "Sweetie Pie."

A. Place items from home in the client's room. B. Place a calendar on the wall across from the client's bed. C. Place a clock on the client's bedside table. Rationale: For those with an altered thought process, routine and patterns are familiar and need to be encouraged. Call the client by name, not an unfamiliar nickname, as the client may not realize who the nurse is talking to. The remaining actions help with orientation.

The nurse is conducting a teaching session with parents of school-age children. What information will the nurse plan on including in the teaching plan to help prevent against child abduction? (Select all that apply.) A. Promote a play-pal, so the child does not go anywhere alone. B. Establish a code word that is only known between the parents and the child. C. Instruct the child to never accept a ride from a stranger or unapproved relative. D. Upon separation of the child in a store, have the child approach a kind-looking person. E. Never allow the child to go outside alone, regardless of the situation.

A. Promote a play-pal, so the child does not go anywhere alone. B. Establish a code word that is only known between the parents and the child. C. Instruct the child to never accept a ride from a stranger or unapproved relative. Rationale: In the event of child/parent separation, the child must seek the assistance of a store employee or a guard. A nice-looking person may not be so nice. School-age children developmentally are increasingly independent and can go outside unsupervised in safe situations. The remaining options are correct actions to help prevent child abduction.

A 6-year-old learns of the recent death of a grandparent. The child and grandparent spent weekends together for the past four years. The parent notes the child has difficulty concentrating and seeks the advice of a healthcare provider. What will the nurse include in the parent's teaching plan? (Select all that apply.) A. Promote activities that the child enjoys. B. Encourage the child to express feelings through coloring. C. Answer the child's questions honestly. D. Make an appointment with a child psychologist. E. Hold and cuddle the child to reinforce closeness.

A. Promote activities that the child enjoys. B. Encourage the child to express feelings through coloring. C. Answer the child's questions honestly. E. Hold and cuddle the child to reinforce closeness. Rationale: A child at this age can realize that death is permanent. The child may find it difficult to concentrate and may even feel responsible for the death. Help the child through this time with pleasurable outlets and activities. There is no need for a child psychologist at this time. The change in behavior is anticipated.

The nurse reviews the laboratory findings for a client's urine drug screen that is positive for cocaine. Which client behavior should be expected during cocaine withdrawal? A. Psychomotor agitation B. Restlessness and hyperactivity C. Detachment from reality and drowsiness D. Distorted perceptions and hallucinations

A. Psychomotor agitation Rationale: During cocaine withdrawal, the nurse should expect option A and a pattern of withdrawal symptoms similar to those of one who uses amphetamines. Options B, C, and D are signs and symptoms of a person who is high on cocaine rather than one who is experiencing withdrawal from cocaine.

The client with Stage 3 Alzheimer's disease suddenly becomes agitated. What actions will the nurse take to settle the client? (Select all that apply.) A. Reassure the client. B. Approach the client slowly. C. Place the client alone in a brightly lit room. D. Speak to the client using a calm tone of voice. E. Use over exaggerated arm movements to get the client's attention.

A. Reassure the client. B. Approach the client slowly. D. Speak to the client using a calm tone of voice. Rationale: Decrease environmental stimuli and stay with the agitated client. Be calm and gesture slowly to decrease agitation. The remaining actions are appropriate for agitation.

After a 20-day stay, the nurse is preparing the client for discharge from the behavioral therapy unit. What will the nurse include in the client's plan of care? (Select all that apply.) A. Refer the client to an outpatient therapist. B. Determine the progress the client thus far. C. Evaluate if the client has met the projected outcomes. D. Work with the client to develop solutions. E. Develop goals for the inpatient behavioral therapy.

A. Refer the client to an outpatient therapist. B. Determine the progress the client thus far. C. Evaluate if the client has met the projected outcomes. Rationale: Developing solutions and goals are nursing actions for inpatient therapy. The foci now are to support the client in an outpatient environment. The remaining selections offer that support.

A client on the behavioral health unit bursts out in a verbal tirade in the dayroom. The client has a history of poor impulse control. What is the nurse's priority action? A. Remove any other clients from the day room. B. Approach the client using a calm tone of voice. C. Acknowledge the client's anger. D. Threaten the use of physical restraints.

A. Remove any other clients from the day room. Rationale: Client safety first. Remove the clients and any potentially harmful objects. Use a calm approach with large personal space. The nurse will need to acknowledge the behavior and actively listen to the client. Threatening may further incite the client.

he nurse is conducting an intake interview for a new client. The client states, "My spouse was just diagnosed with pancreatic cancer. I do not know what to do." The client's plan of care will reflect which type of crisis? A. Situational B. Emotional C. Adventitious D. Maturational

A. Situational Rationale: There are three generally acceptable types of crisis. Situational crisis involves an unanticipated external source such as loss of a job, divorce, serious illness or death. An adventitious crisis often involves a disaster or is an event that is not a part of everyday life, such as flood, earthquake, fire, war, or murder. A maturational crisis includes role changes in life such as marriage or the birth of a child.

A woman brings her 48-year-old husband to the outpatient psychiatric unit and tells the nurse that he is being treated for dissociative disorder. Which data are consistent with this diagnosis? (Select all that apply.) A. Sleepwalking B. Unable to remember who he is C. Has recurrent intrusive obsessions D. Acute attack of anxiety E. Exhibits multiple personalities

A. Sleepwalking B. Unable to remember who he is E. Exhibits multiple personalities Rationale: Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness and are consistent with a diagnosis of dissociative disorder (A, B, E). (C) is consistent with obsessive-compulsive disorder. (D) is associated with neuro-cognitive disorders.

The therapy nurse is working with a group of nine veterans who observed traumatic death and violence on a daily basis while on duty. What actions will the nurse include in the veterans' plan of care? (Select all that apply.) A. Speak using a calm nonaccusatory tone of voice, and do not pass judgment. B. With each subsequent session, explore each traumatic experience more deeply. C. Encourage each veteran to express current feelings to survival of the traumatic event. D. Insist each veteran attend all sessions or anticipate expulsion from the group. E. Have the veterans live in isolation of close family and friends, until resolution of the PTSD.

A. Speak using a calm nonaccusatory tone of voice, and do not pass judgment. B. With each subsequent session, explore each traumatic experience more deeply. C. Encourage each veteran to express current feelings to survival of the traumatic event. Rationale: Expulsion from the group does not establish or promote trust in the nurse-client relationship. While participating in group therapy can help bring resolution, insisting on presence may not promote participation. With appropriate counseling, family and friends can be a source of comfort, and isolation from them is not encouraged. The remaining items will assist the veterans in working towards resolution of the PTSD.

The nurse assess a client on an inpatient behavioral unit is becoming increasingly anxious. What initial actions should the nurse take for this client? (Select all that apply.) A. Stay by the client's side. B. Escort the client to a quiet place. C. Use a comforting tone of voice when speaking to the client. D. Ask a coworker to call the client's family. E. Ask the medication aid to prepare a sedative.

A. Stay by the client's side. B. Escort the client to a quiet place. C. Use a comforting tone of voice when speaking to the client. Rationale: The goal for the nurse of a client with anxiety is to reduce stimuli to decrease the client's anxiety. The nurse must stay with the client until the anxiety diminishes or further assistance is needed. The family will need to be notified, but the initial actions need to be client focused. A chemical restraint is an alternative when there is no resolution to the client's highly anxious condition.

The parent and a 6-year-old present to the clinic for routine well-child care. The child weighs 35 pounds 15.9 kg; is wearing torn and dirty clothing; and, sits quietly with an apparent subtle rocking motion. What are the nurse's next actions? (Select all that apply.) A. Take the child's height, and vital signs. B. Check the clothing closet at the clinic for size appropriate clothing. C. Assess the child for any bruising, or lacerations. D. Ask the accompanying parent to leave the room. E. Ask the child about attendance at school. F. Stay with the child during the healthcare provider's assessment.

A. Take the child's height, and vital signs. C. Assess the child for any bruising, or lacerations. D. Ask the accompanying parent to leave the room. E. Ask the child about attendance at school. F. Stay with the child during the healthcare provider's assessment. Rationale: Checking for appropriate clothing is a nice gesture, but that action does nothing to protect the child or assess for further signs of neglect. The remaining assessments will help validate for neglect. The normal height and weight for this child should be 45 pounds/20.4 kg and 45 inches/114 cm. This child is underweight for its age, but a height and comparison of stature to the parents will help confirm those findings. The subtle rocking motion may be an indication of emotional abuse. The goal of the nurse is to provide a safe and secure environment for the child. Nurses are mandatory reporters for suspected abuse.

he nurse notes multiple burns on the arms and chest of a 2-year-old Vietnamese child who is being treated for dehydration. When questioned, the child's father states that he treated the child's vomiting with the cultural practice termed coining, which resulted in burned areas. Which expected outcome statement has the highest priority? A. The child will be protected from further harm. B. The family's cultural values will be respected. C. The parents will express regret at harming their child. D. The parents will demonstrate an ability to care for burn wounds.

A. The child will be protected from further harm. Rationale: The nurse's highest priority is to ensure that no further harm befalls the child. Options B, C, and D are also important objectives but are secondary to option A.

The nurse at an adult day care center is assessing a new client. The nurse is concerned the client has dementia. Which characteristics support the nurse's concern? (Select all that apply.) A. The client cannot remember what was served for breakfast 30 minutes ago. B. The client thinks it is permissible to drive without a license. C. The client's favorite foods no longer taste good. D. The client uses splitting behavior with the day care personnel. E. The client now remembers to eat without being prompted.

A. The client cannot remember what was served for breakfast 30 minutes ago. B. The client thinks it is permissible to drive without a license. Rationale: With dementia the client can display short and long-term memory loss, and impaired judgment. Generally, there is no loss of taste buds with dementia. Those with dementia lack the cognitive ability to use splitting behaviors. Dementia is evident in a deficit in self-care, and is not reversible.

The therapy nurse is working with a client admitted with an erratic type of personality disorder. Which client behaviors indicate to the nurse that the therapy is beginning to be effective? (Select all that apply.) A. The client no longer wishes to do self-harm. B. A happy and bright affect is evident in the client's face. C. The client no longer displayed manipulative behaviors. D. Attention seeking behaviors are no longer evident. E. The client is no longer hearing voices that are not present.

A. The client no longer wishes to do self-harm. C. The client no longer displayed manipulative behaviors. D. Attention seeking behaviors are no longer evident. Rationale: The client with depression would display a bright affect. When a client is talking to voices, that client is having auditory hallucinations. The remaining behaviors are signs that a client with a personality disorder is improving.

The nurse is providing care to four clients. Which client will the nurse assess for symptoms of withdrawal? A. The client who consumes 800 mL of grain alcohol every day for 3 years B. The college-age client who drank 12 beers for the first time at a party the night before C. The client who mixed 300 mL of wine with a sleeping tablet D. The client who reports a headache after drinking red wine

A. The client who consumes 800 mL of grain alcohol every day for 3 years Rationale: This client displays tolerance to a large quantity of alcohol over an extended period. Physiological dependence occurs when the client consumes the addictive substance in ever-increasing quantities to avoid withdrawal symptoms. The college-age client will likely experience alcohol poisoning with a large amount of beer in one evening. The client who mixed alcohol with a sleeping table needs to be assessed for respiratory depression, but will not experience symptoms of withdrawal. Histamines are more prevalent in red wine and can cause headaches.

The nurse is developing a plan of care for a client on disulfiram therapy. Which products will the nurse include in the plan as items that must be avoided while taking this medication? (Select all that apply.) A. Hairspray B. Mouthwash C. Toothpaste D. Aftershave products E. Cough medicines

B. Mouthwash D. Aftershave products E. Cough medicines Rationale: The client must avoid products that contain alcohol. The client must vigilantly read labels of products for alcohol. Hairspray may contain alcohol, but it is not absorbed into the system. Toothpaste contains no alcohol.

The client states to the nurse during 1:1 therapy, "I have been having trouble sleeping the last few nights." What is the nurse's best response? (Select all that apply.) A. "Are you sure you have not closed your eyes even once?" B. "I have seen you up very early in the morning." C. "Help me understand what 'having trouble' means." D. "Ask the night shift medication nurse for a sleeping pill." E. "Do you get up and watch TV all night long?"

B. "I have seen you up very early in the morning." C. "Help me understand what 'having trouble' means." Rationale: The nurse validates seeing the client awake early in the morning and also uses open ended questioning for further exploration of trouble sleeping. Asking about closed eyes is confrontational and indicates the nurse does not believe the client's statement. Asking for a sleeping pill, does not address the root cause of the sleeping trouble. Asking about the client's actions through the night is a yes/no question that does not address any of the issues that may be causing the trouble.

The clinic nurse notes bruises in various stages of healing on the client's back and legs. What questions must the nurse include in the client's assessment? (Select all that apply.) A. "Those bruises are shocking! What happened to you?" B. "Is anyone hurting your back and legs?" C. "I see you have lots of bruises. Are you very clumsy?" D. "When you and your spouse disagree, what happens to you?" E. "Has your spouse ever threatened you verbally or with violence?"

B. "Is anyone hurting your back and legs?" D. "When you and your spouse disagree, what happens to you?" E. "Has your spouse ever threatened you verbally or with violence?" Rationale: Developing trust in providing a calm, nonjudgmental approach is essential when working with suspected abuse victims. By stating, "Those bruises are shocking" is alarmist, and does not place the client at ease. Asking if the client is clumsy give the client a way to not identify if abuse is occurring. The remaining questions are appropriate to assess for physical abuse.

he nurse recognizes a client is rationalizing the outburst that just occurred in the dayroom. Which statement best reflects the nurse's assessment? A. "I feel so bad about throwing the chairs around in the dayroom." B. "It was okay that I broke the chairs; they were old anyway." C. "I honestly do not remember throwing chairs in the dayroom." D. "I just got so mad, I had to break the chairs that were right there."

B. "It was okay that I broke the chairs; they were old anyway." Rationale: Rationalizing is the act of making an unacceptable act acceptable. Remorse describes option A. Repression describes option C. Displacement is the subject of option D.

At the first meeting of a group at a daycare center for older adults, the nurse asks one of the members what kinds of things the client would like to do with the group. The older adult shrugs and says, "You tell me. You're the leader." What would be the best response for the nurse to make? A. "Yes, I am the leader today. Would you like to be the leader tomorrow?" B. "Yes, I will be leading this group. What would you like to accomplish?" C. "Yes, I have been assigned to lead this group. I will be here for the next 6 weeks." D. "Yes, I am the leader. You seem angry about not being the leader yourself."

B. "Yes, I will be leading this group. What would you like to accomplish? Rationale: Anxiety over participation in a group and testing of the leader characteristically occur in the initial phase of group dynamics. Option B provides information and refocuses the group to defining its function. Option A is manipulative bargaining. Option C does not focus the group on its purpose or task. Option D is interpreting the client's feelings and is almost challenging.

A 33-year-old client is admitted to a psychiatric facility with a medical diagnosis of major depression. When the nurse is assigning the client to a room, which roommate is best for this client? A. A 35-year-old client who recently attempted suicide B. A manic client who has started lithium carbonate treatment C. A client who is bipolar and is pacing the floor while telling jokes to everyone D. A paranoid client who believes that the staff is trying to poison the food

B. A manic client who has started lithium carbonate treatment Rationale: Option B appears to be the most stable client described since treatment was begun with lithium carbonate (treatment of choice for manic depression). Being around another depressed individual might enhance this client's own depression and possibly support suicidal ideation. Clients in the manic stage of bipolar disease enhance the level of anxiety of those around them, which would not be therapeutic for the client at this time. Paranoid ideation, which is characterized by suspiciousness, would also increase anxiety in this client.

The nurse is planning care for a client in the depressed phase of bipolar disorder. What foods will the nurse include in the client's plan of care? (Select all that apply.) A. A chocolate and caramel candy bar B. Celery filled with peanut butter C. A mixture of nuts and dried fruit D. Greek yogurt with mixed berries and granola E. Dried "O" shaped wheat cereal without milk

B. Celery filled with peanut butter C. A mixture of nuts and dried fruit D. Greek yogurt with mixed berries and granola Rationale: The goal is to offer small, high calorie and high protein nutritional foods throughout the day. The depressed client will often feel like not eating. Hand-held foods could be less intimidating to eat in lieu of a large meal. A chocolate caramel candy bar is filled with empty calories. "O" shaped cereal has carbohydrates but little protein.

The nurse assesses a new client admitted to an eating disorders unit in a behavioral health facility. The assessment reveals a female client, 18 years old, height 5′6″/167 cm and weight 108 pounds/49 kg. Temperature, blood pressure, and pulse are all below the anticipated findings for a client at this age. Which additional outward findings will the nurse look for in this client? (Select all that apply.) A. Bone demineralization B. Complaints of constipation C. Electrolyte imbalances D. Gum deterioration E. Scaly skin

B. Complaints of constipation D. Gum deterioration E. Scaly skin Rationale: Bone demineralization is apparent on bone density screening. Electrolyte imbalances are apparent in blood work. There are outward signs of these findings such a fractures for demineralization, and muscle cramping for low magnesium, calcium and/or potassium. However, those signs and symptoms were not listed. The remaining are physical signs of a client with anorexia nervosa.

The nurse manager is working with architects and child abduction specialists to design a state-of-the-art maternal-infant care unit. What safety features will the nurse manager request of the design team? (Select all that apply.) A. Make all rooms semiprivate rooms. B. Design the nurse's station so all exits are visible. C. Install an infant security monitoring system with sensor infant bands. D. Require all access points to the unit are monitored by a security camera. E. All doors must have electronic locks that can only be opened by approved personnel.

B. Design the nurse's station so all exits are visible. C. Install an infant security monitoring system with sensor infant bands. D. Require all access points to the unit are monitored by a security camera. E. All doors must have electronic locks that can only be opened by approved personnel. Rationale: Private rooms offer the best security as it decreases the visitor traffic to only those known to the client. All security measures are to help prevent newborn abduction. Additionally, place matching bands on both parents, or close family relative (like the client's mother) and check to make sure the infant is transported only by hospital personnel or appropriately banded family.

Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. Which action should the nurse take first? A. Remind the client to wear the nicotine patch. B. Determine if the client still needs constant observation. C. Encourage the client to attend the smoking cessation group. D. Explain that clients on constant observation cannot smoke.

B. Determine if the client still needs constant observation. Rationale: The nurse should continually reassess the need for constant observation so that the client can have unit privileges such as outdoor breaks. Options A and C do not meet the client's need and desire to smoke. Option D will cause more agitation.

What instructions should the nurse include in the discharge teaching plan of a client who has recently been prescribed oxazepam? (Select all that apply.) A. Take the medication in the morning for best results. B. Do not combine this medication with alcohol. C. This medication is typically used for short-term treatment. D. Stop the drug immediately if sleepiness occurs. E. Avoid driving or operating equipment while taking this drug.

B. Do not combine this medication with alcohol. C. This medication is typically used for short-term treatment. E. Avoid driving or operating equipment while taking this drug. Rationale: Harm can occur if oxazepam is taken with alcohol or other central nervous system (CNS) depressants (B). Oxazepam is a benzodiazepine used for the short-term treatment of anxiety (C). Sleepiness is an expected side effect; therefore, driving or operating equipment should be avoided (E). The drug should be taken in the evening because of sedation effects (A) and should be tapered, not immediately stopped, because of withdrawal effects (D).

A client of the Jewish faith is readmitted to the behavioral treatment unit with a diagnosis of depression. Which nurse's statement would the manager need to correct? A. "Can I contact your Rabbi for you to provide spiritual comfort?" B. "Have you been saved by accepting Christ into your life?" C. "When you have been depressed before, has your faith been helpful?" D. "What can I do to help you to seek spiritual support at this time?"

B. Have you been saved by accepting Christ into your life?" Rationale: The nurse must be sensitive to the spiritual and cultural values of each client and must not impose personal values upon clients. Those of the Jewish faith recognize Jesus as a prophet, but not the savior. Statement A supports a client of the Jewish faith. The remaining statements are useful for any client who has faith or spirituality.

The nurse is in a 1:1 session with a client who reportedly drinks 750 mL of vodka per day. What questions will the nurse include in the initial client assessment? (Select all that apply.) A. Have you kept a journal of your sleep/wake patterns? B. Have you ever wanted to drink less vodka in a day? C. Have you ever gotten angry with someone who points out to you how much vodka you drink? D. Have you ever had a drink early in the morning to get yourself up and moving? E. Have you ever felt guilty after the fact about behaviors displayed when drinking vodka?

B. Have you ever wanted to drink less vodka in a day? C. Have you ever gotten angry with someone who points out to you how much vodka you drink? D. Have you ever had a drink early in the morning to get yourself up and moving? E. Have you ever felt guilty after the fact about behaviors displayed when drinking vodka? Rationale: Journaling about any behaviors is a technique to seek reflection and understanding about behaviors. Sleep/wake patterns are not the primary concern for this client. Addictive behavior is the primary concern and the focus of the remaining questions.

A 25-year-old client has suffered extensive burns and is crying during dressing change treatment. The client tells the nurse, "Please let me die. Why are you all torturing me like this? I just want to die." Which response by the nurse is best? A. "We aren't torturing you. These treatments are necessary to prevent a terrible infection." B. "I know these treatments must seem like torture to you, but we want to help you recover." C. "You have so much to live for, and all of your family members want you to live." D. "Would you like me to call the chaplain so that you can discuss your feelings privately?"

B. I know these treatments must seem like torture to you, but we want to help you recover." Rationale: Options B offers an empathetic response without sounding patronizing. Options A is not empathetic and is actually somewhat argumentative. The client is not asking for information as much as pleading for understanding. Option C appears as scolding and places blame on the client for wanting to die and possibly hurting the client's family members as a result. Option D might be appropriate if the nurse simply asks the client if a chaplain's visit is desired, but the nurse is dismissing the client's needs by not addressing them at the moment.

The nurse is providing instructions for disulfiram therapy. Which client statement indicates an understanding of the instructions? A. I can drink alcohol up to 4 hours before I start the therapy. B. I will not drink alcohol during and after the therapy. C. If I drink alcohol with the therapy I will break out in a rash. D. After I complete the therapy, I will no longer be an alcoholic.

B. I will not drink alcohol during and after the therapy. Rationale: Alcohol consumption during and up to 14 days after therapy can cause a disulfiram-alcohol reaction which includes headache, flushing, shortness of breath, nausea, vomiting, dizziness, tiredness, fainting, irregular tachycardia, and blurry vision. No alcohol should be consumed for up to 12 hours before initiating therapy. The client will always be an alcoholic, whether recovering or not.

A client on the psychiatric unit seeks out a particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client? A. Sublimation B. Identification C. Introjection D. Repression

B. Identification Rationale: Identification is an attempt to be like someone or emulate the personality traits of another. Option A is substituting an unacceptable feeling with one that is more socially acceptable. Option C is incorporating the values or qualities of an admired person or group into one's own ego structure. Option D is the involuntary exclusion of painful thoughts or memories from one's awareness.

The nurse cares for an adolescent with a history of violence who now exhibits signs of sublimation. Which behavior by the adolescent best represents sublimation? A. Recently started wetting the bed B. Joined a competitive boxing team C. Kicks the dog after being scolded by his dad D. Starts a student organization to ban violence

B. Joined a competitive boxing team Rationale: Sublimation is a coping mechanism characterized by substituting an unacceptable feeling or action with a more socially acceptable one. Option A is an example of regression, Option C is characteristic of displacement, and Option D is consistent with undoing.

The nurse is performing in-service training on bullying to a group of elementary school teachers. The nurse indicates that the teachers must be alert to the signs a child is being bullied. What signs will the nurse share with the teachers? (Select all that apply.) A. Retaliation B. Low self-esteem C. Depression D. Social withdrawal E. Incoordination

B. Low self-esteem C. Depression D. Social withdrawal Rationale: The bullied child regresses inwardly and retaliation is often not observed. Incoordination is not a sign of bulling. The remaining are signs of bulling.

A newly admitted client to the behavioral health unit states, "I think my own mother is out to kill me. I saw her yesterday in the kitchen cutting up vegetables. I know that knife was meant for me." The nurse will initiate a plan of care based on which most likely medical diagnosis? A. Depression B. Paranoid disorder C. Tactile hallucinations D. Delusions

B. Paranoid disorder Rationale: Those who are paranoid demonstrate suspiciousness and mistrust. Depressive behavior is characterized by profound feelings of sadness. Tactile hallucinations touch sensations in the absence of any stimuli. Delusional thinking involves a belief thought to be true, even when presented with evidence that the thought is not true.

The nurse is providing care to a client with Alzheimer's disease. Which actions will the nurse include in the client's plan of care? (Select all that apply.) A. Finish buttoning the client's shirt when there are 2 buttons remaining opened. B. Place a picture of the client's family on the bedroom door. C. Walk with the client for 15 minutes at the same time every day. D. Do all activities of daily living for the client. E. Place the client in a darkened room for 2 hours every day.

B. Place a picture of the client's family on the bedroom door. C. Walk with the client for 15 minutes at the same time every day. Rationale: The nurse needs to assist the client in maintaining independence. Finish buttoning the client's shirt does not allow the client time to finish a task. The client needs activities that occupy and distract; a darkened room does not accomplish this goal. Provide the client with familiar surroundings and help the client establish a healthy routine.

client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. Which action should the nurse take first? A. Notify the health care provider immediately and force fluids. B. Prior to giving the next dose, notify the health care provider of these symptoms. C. Record the symptoms and continue with medication as prescribed. D. Hold the medication and refuse to administer additional doses.

B. Prior to giving the next dose, notify the health care provider of these symptoms. Rationale: Although these are expected symptoms, the health care provider should be notified prior to the next administration of the drug. Early side effects of lithium carbonate (occurring with serum lithium levels below 2 mEq/L) generally follow a progressive pattern, beginning with diarrhea, vomiting, drowsiness, and muscular weakness (option C). At higher levels, ataxia, tinnitus, blurred vision, and large dilute urine output may occur. Option A will lower the lithium level. Option D is not warranted.

An adult client who lives in a residential facility is mentally delayed and has a history of bipolar disorder. During the past week, the client has refused to wear clothes and frequently engages in exposure to other residents. Which action should the nurse take first? A. Establish a one-to-one relationship to discuss the behavior. B. Redirect the client to physically demanding activities. C. Encourage the client to verbalize thoughts when acting out. D. Restrict social interactions with other residents in the facilit

B. Redirect the client to physically demanding activities. Rationale: The client is exhibiting manic behavior related to bipolar disorder, and the nurse should redirect the client to activities that are physically demanding so that energy can be expended in a socially acceptable manner. Psychotic clients are not capable of option A. When exhibiting acting-out behavior, the client is distracted and option C is difficult. Option D is likely to increase manic behaviors, such as mood swings and acting-out behaviors.

The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, has lost 10 pounds in 2 weeks, and is sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge? A. Tries to interact with a few peers and staff B. Reports feeling better and less depressed C. Sits attentively with peers in group therapy D. Easily awakens for morning medications

B. Reports feeling better and less depressed Rationale: The client is experiencing symptoms of depression, and the outcome by discharge for this client would be that the client reports feeling better and less depressed. The client may interact with peers and staff and sit attentively in groups without any improvement in depression. Difficulty awakening is usually caused by the medication regimen for depression, so awakening is not an indication of improvement.

The client states to the therapy nurse, "I cannot remember a thing about any of the times my parent would burn me with a cigarette. I know it happened because I have the scars and my family tells me of those times." When developing the client's plan of care, which defense mechanism will the nurse include? A. Repression B. Suppression C. Displacement D. Denial

B. Repression Rationale: Repression is the unconscious blocking of difficult thoughts. Suppression is deliberately forgetting painful thoughts. Displacement is the act of redirecting feelings to a less threatening object. Denial is consciously rejecting difficult thoughts.

The nurse on the behavioral unit notices a change in the client's behavior. When voluntarily admitted, the client appeared sad with mournful eyes, and frequent sighing. Upon the morning assessment, the client is noncommunicative and displays continuous rocking motions. What is the nurse's next action? A. Contact the client's family. B. Review the client's medication list. C. Hug the client in an attempt to stop the rocking. D. Tell the client to stop rocking immediately.

B. Review the client's medication list. Rationale: Assessment first to determine if the client's behaviors may be related to any of the medications. The family will need to be informed of the change in behavior, but not until a thorough assessment for the new onset has been completed. Since the client is not if harm to self or others, there is no need for the nurse to intervene to stop the behavior.

The nurse encounters a client with bipolar disorder in an aggressive state. What is the priority nursing action for this client? A. State to the client, "You need to settle down now!" B. Say, "If you throw that lamp you will need to stay in your room for 1 hour." C. Call an alert to summon security and prepare a sedative. D. Place the client in a restraint vest and in a quiet room.

B. Say, "If you throw that lamp you will need to stay in your room for 1 hour." Rationale: The nurse needs to indicate to the client the consequences of aggressive behavior. Stating you need to settle down is nontherapeutic for the aggressive client. Calling security can precipitate more agitation. A restraint vest and a quiet room is a last resort for the aggressive client and should be used only when the client is at risk for harm to self or others. There is no indication in the stem that there is a risk for harm, only aggression.

The nurse observes a client with Alzheimer's disease wandering. What actions will the nurse take for this client? (Select all that apply.) A. Tell the client, "It is time for sleep." B. Secure all doors to stairwells and outdoors. C. Walk with the client. D. Remind the client it is 2:00 am. E. Provide the client a clear path.

B. Secure all doors to stairwells and outdoors. C. Walk with the client. E. Provide the client a clear path. Rationale: Wandering is common for those with Alzheimer's. The nurse must provide a safe environment and prevent unsafe wandering. Those with Alzheimer's often get their nights and days mixed up so reminding them of the time is not useful to them. As long as the client is closely supervised and safe, there is no reason to prohibit the client from wandering.

Physical examination of a 6-year-old boy reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate? A. "I need to tell the health care provider about your child's tendency to be accident-prone." B. "Tell me more about these accidents that your child has been having." C. "I need to report these injuries to the authorities because they do not seem accidental." D. "Boys this age always seem to require more supervision and can be quite accident-prone."

B. Tell me more about these accidents that your child has been having." Rationale: Option B seeks more information using an open-ended, nonthreatening statement. Option A might be appropriate but is not the best answer because the nurse is being somewhat sarcastic and is also avoiding the situation by referring it to the health care provider for resolution. Although it is true that suspected cases of child abuse must be reported, option C is almost an attack and is jumping ahead before conclusive data are obtained. Option D is a cliché and dismisses the seriousness of the situation.

A client reports to the nurse a profound feeling of sadness after the loss of a close parent. What is the nurse's best response? A. "Are you also feeling disbelief?" B. "What you are feeling is a part of the grieving process." C. "You will work through those feelings quickly." D. "Next you will accept the reality of the death."

B. What you are feeling is a part of the grieving process." Rationale: The nurse acknowledges the client's feelings as a phase in the fluid process of grief. Shock and disbelief are often seen in the first phase. Bargaining, guilt, and depression are often signs of the second stage of grief. Accepting the loss is the third stage. Indicating working through the feelings quickly is nontherapeutic. While the next stage after depression is acceptance, this statement does not acknowledge the client's statement.

A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows that he is not. What is the nurse's best response? A. "Did you really believe you were Jesus Christ?" B. "I think you're getting well." C. "Others have had similar thoughts when under stress." D. "Why did you think you were Jesus Christ?"

C. "Others have had similar thoughts when under stress." Rationale: Option C offers support by assuring the client that others have experienced similar situations. Option A is belittling. Option B is making an inappropriate judgment. You may have narrowed your choices to options C and D. However, you should eliminate option D because it is a "why" question, and the client does not know why.

Which activity will the nurse plan for the client in a manic phase of bipolar disorder? A. Puzzles B. Volleyball C. Aerobics class D. Flag football

C. Aerobics class Rationale: An aerobics class will help the client burn off excess energy. Puzzles can be frustrating and they use little energy. Volleyball uses energy, but is competitive, as is flag football. Competitive sports need to be avoided in the manic phase.

A client on the behavioral health unit is newly admitted with schizophrenia, and appears to be in a stupor. What is the nurse's best action? A. Position the client with others making cookies in the kitchen. B. Place the client with two other inpatients quietly playing cards. C. Calmly sit with the client in five-minute intervals. D. Escort the client to a dark room to sit alone.

C. Calmly sit with the client in five-minute intervals. Rationale: Having intermittent, but a short-term presence with the client will help establish trust while not overwhelming the client. One-on-one interactions are best initially, then progressing to small group activities. The client does not need to be alone in a dark place.

A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveals no significant changes, and the nurse formulates the diagnosis of confusion related to ICU psychosis. Which nursing action is best for this client's behavior? A. Move all medical equipment away from the client's bedside. B. Allay fears by teaching the client about the causes of the disease. C. Cluster care to allow for brief rest periods during the day. D. Encourage visitation by the client's family members, including the client's young children.

C. Cluster care to allow for brief rest periods during the day. Rationale: The best intervention is to organize care so that the client can experience rest periods. The critical care unit contains many lifesaving treatment modalities that offer clients an array of auditory, visual, and even painful stimuli. These stressors can result in isolation and confusion. Option A is not practical because the client may need assistance from medical equipment to survive. The client is too ill to receive teaching (Option B). Although option D may be supportive, young children are routinely prohibited from critical care units because of increased risk of infectious disease transmission.

A 24-year-old female presents to the emergency department with her best friend. She states to the intake nurse, "My husband forces me to have sex with him 2 to 3 times every day. Sometimes I tell him I don't want to, but then he gets mean with me, forces me on my stomach and has anal sex with me." What are the nurse's next actions? (Select all that apply.)

C. Contact a S.A.N.E. nurse. D. Assist the client into a private exam room. Rationale: Marital sexual abuse occurs when the spouse does not consent to a sexual act. Asking about the client's intentions toward nonconsensual sex is nontherapeutic and does not support the client's chief complaint. SANE nurses are trained in conducting an examination for sexual abuse victims. The client needs a quiet, private space. The best friend is the client's support system and can initially accompany the client to help ease the transition to the medical environment.

What is the primary goal of the nurse in the initial inpatient treatment for the client with anorexia nervosa? A. Achieve high esteem in the client. B. Create a written contract for nutritional intake. C. Establish a trusting relationship. D. Restore elimination patterns.

C. Establish a trusting relationship. Rationale:The primary goal is to establish trust as the remaining actions occur on a foundation of trust. The client may not exhibit signs of self-esteem while an inpatient as this may take longer to accomplish. A written contract follows the establishment of trust. Without trust the contract may not be followed. Elimination patterns may be restored with a balanced, nutritional diet and adequate fluid intake.

The nurse is reviewing signs and symptoms of Alzheimer's disease with a new nurse to the unit. Which definition indicates the new nurse understands the term aphasia? A. Failure to recognize a family member. B. Loss of memory caused by degeneration of the brain. C. Language disturbance in understanding and stating words. D. Inability to perform motor activities.

C. Language disturbance in understanding and stating words. Rationale: Failure to recognize familiar objects or family members is agnosia. Amnesia is the loss of memory. In addition, apraxia is the inability for motor activities, despite intact motor function.

On admission, a depressed client tells the nurse, "I can't eat because my tongue is rubber." Which is the best action for the nurse to take? A. Provide packaged foods for the client to eat. B. Begin the client on total parenteral nutritional (TPN) therapy. C. Provide a well-balanced liquid diet for the client. D. No action is necessary because the client will eat when hungry.

C. Provide a well-balanced liquid diet for the client. Rationale: The nurse should strive to provide a safe environment (adequate nutrition is part of a safe environment) and should not argue with the client's delusions. Option C is the least invasive while providing nutrition that does not argue with the client's delusion. Option A is given to those with paranoid delusions. Option B is invasive and would be used as a last resort. Option C should be tried first. This client's delusion could be life threatening and should not be ignored.

A client on the psychiatric unit, diagnosed with bipolar disorder, becomes loud and shouts at one of the nurses, "You fat tub of lard, get something done around here!" What is the best initial action for the nurse to take? A. Have the staff escort the client to his room. B. Tell the client that his behavior will be documented in his record. C. Redirect the client by offering an activity such as playing card games. D. Review the medication record for an antipsychotic drug.

C. Redirect the client by offering an activity such as playing card games. Rationale: Distracting the client, or redirecting him toward a constructive activity, prevents further escalation of the inappropriate behavior. Option A could result in escalating the abuse and might unnecessarily involve another staff member in the abusive situation. Option B may be more threatening to the client. Option D may be indicated if the behavior escalates, but at this time the best initial action is option C.

A nurse working in the emergency department of a children's hospital admits a child whose injuries could have been the result of abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? A. Obtain objective data such as radiographs before reporting suspicions. B. Confirm suspicions of abuse with the health care provider. C. Report any case of suspected child abuse. D. Document injuries to confirm suspected abuse.

C. Report any case of suspected child abuse. Rationale: It is the nurse's legal responsibility to report all suspected cases of child abuse, and notifying the nurse manager or charge nurse starts the legal reporting process. Options A, B, and D delay the first step in reporting the abuse.

An 8-year-old child is seen in the clinic with a green vaginal discharge. Which action is most important for the nurse to implement? A. Assess the child's blood pressure. B. Counsel the child to wear cotton underwear. C. Report as suspected child abuse. D. Determine if the child takes bubble baths.

C. Report as suspected child abuse. Rationale: A green vaginal discharge is indicative of gonorrhea, a sexually transmitted disease. Because the child is 8 years old, the nurse should suspect child abuse and report the incident to the proper authorities. Option A is usually not related to infection. Options B and D are helpful in preventing bladder infections, but a green vaginal discharge is not a symptom of a bladder infection.

The emergency department nurse assesses a new client and finds constricted pupils, drowsiness, impaired memory, and slurred speech. Which vital sign would be most concerning to the nurse? A. B/P 108/64 mm Hg B. Temperature 99°F/37.2°C C. Respirations 10 breaths/min D. Pulse 64 beats/min

C. Respirations 10 breaths/min Rationale: The client is demonstrating signs of opioid intoxication. Depression of the respiratory center is most concerning for this client. Blood pressure and pulse can also run low with opioid intoxication. The temperature is mildly elevated.

An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle collision. The nurse includes in the client's plan of care, "Observe for signs of delirium tremens." Which early signs indicate that the client is beginning to have delirium tremens? A. Abdominal cramping and watery eyes B. Depression and fatigue C. Restlessness and confusion D. Hostility and anger

C. Restlessness and confusion Rationale :A client experiencing alcohol withdrawal often has delirium tremens (DTs), which are characterized by progressive disorientation. Initially, the client will appear restless and confused and develop tachycardia, tachypnea, and diaphoresis. Hallucinations, paranoia, and seizures can also occur later in the development of DTs. Option A is indicative of withdrawal from opiates such as heroin or morphine. Option B is often seen in cocaine withdrawal. Option D is most characteristic of the paranoid client.

The client states to the nurse on the behavioral unit, "I do not want to stay in treatment any longer. I am feeling better, and I want to go home." What is the nurse's next action? A. Ask the health care provider (HCP) for a discharge order. B. Call the family and let them know the client is being discharged. C. Review the client's chart for the type of admission to the unit. D. State to the client, "You have 5 days left in treatment."

C. Review the client's chart for the type of admission to the unit. Rationale: With a voluntary admission to the behavioral unit, the client has the right to request discharge and release. The nurse needs to verify the chart for the type of admission. If the client was voluntarily admitted, the nurse needs to inform the (HCP) if the client's statements and request discharge. The family can then be notified. Clarification of length of stay would be appropriate for the client admitted involuntarily.

A child is brought to the emergency department with a broken arm. Because of other injuries, the nurse suspects that the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? A. She is regressing to an earlier behavior pattern. B. She is sublimating her anger. C. She is projecting her feelings onto the nurse. D. She is suppressing her fear.

C. She is projecting her feelings onto the nurse. Rationale: Projection is attributing one's own thoughts, impulses, or behaviors onto another; it is the mother who is probably harming the child, and she is attributing her actions to the nurse. The mother may be immature, but option A is not the best description of her behavior. Option B is substituting a socially acceptable feeling for an unacceptable one. These are not socially acceptable feelings. The mother may be suppressing her fear (option D) by displaying anger, but such an interpretation cannot be concluded from the data presented.

A middle-aged client tells the clinic nurse, "I'm again starting to feel overwhelmed and anxious with all my responsibilities. I don't know what to do." What is the nurse's best response? A. "Describe in more detail your feelings about being overwhelmed." B. "Why don't you give up some of your commitments?" C. "What has worked for you in the past?" D. "I know, but it is important to take time for yourself."

C. What has worked for you in the past?" Rationale: A nurse can help the client solve problems by identifying past coping mechanisms that could be transferred into current situations that the client finds to be overwhelming. The client has already expressed some degree of hopelessness (overwhelmed and anxious), so option A is redundant. Option B is advice giving and may not be possible for the person, and this response does not encourage the client to employ known methods of coping. Option D is also considered advice giving, with an implied value judgment.

The clients report feelings of helplessness about their weigh

Call the nursing supervisor.

On admission, a highly anxious client is described as delusional. Delusions are most likely to occur with which disorders? A. Dissociative disorders B. Personality disorders C. Anxiety disorders D. Psychotic disorders

D. Psychotic disorders Rationale: Delusions are false beliefs characteristic of psychosis.

A 25-year-old client has been particularly restless, and the nurse finds the client trying to leave the psychiatric unit. The client tells the nurse, "Please let me go! I must leave because the secret police are after me." What is the nurse's best response? A. "No one is after you. You're safe here." B. "You'll feel better after you have rested." C. "I know you must feel lonely and frightened." D. "Come with me to your room, and I will sit with you."

D. "Come with me to your room, and I will sit with you." Rationale: Option D is the best response because it offers support without judgment or demands. Option A is challenging the client's delusion. Option B is offering false reassurance. Option C is a violation of therapeutic communication because the nurse is telling the client how she or he feels (frightened and lonely), rather than allowing the client to describe his or her own feelings. Hallucinating and delusional clients are not capable of discussing their feelings, particularly when they perceive a crisis.

A client states to the new nurse, "I can't tell you something important because you will tell the other nurses." What is a therapeutic response by the new nurse? (Select all that apply.) A. "I promise not to tell anyone what is on your mind; your concerns are safe with me." B. "What you share with me is confidential; I guarantee I will not say a word to anyone." C. "You can trust me not to tell your concerns to the other nurses." D. "Since the information you have is important to you; I encourage you to share." E. "I urge you to tell me what is on your mind; you have something to disclose."

D. "Since the information you have is important to you; I encourage you to share." E. "I urge you to tell me what is on your mind; you have something to disclose." Rationale: The nurse cannot promise not to tell/share information. That is never appropriate in a therapeutic relationship. It is therapeutic to encourage the client to share important information.

he nurse on the behavioral health unit is concerned a new admission will develop withdrawal delirium. During which timeframe will the nurse pay particular attention to this client? A. 1 to 12 hours after last consumption B. 12 to 18 hours after last consumption C. 18 to 48 hours after last consumption D. 48 to 72 hours after last consumption

D. 48 to 72 hours after last consumption Rationale: Withdrawal delirium is a medical emergency that can include client death after a myocardial infarction, vascular collapse, aspiration, embolism, and electrolyte imbalance. The height of occurrence appears 48 to 72 hours after last consumption.

A client mumbles out loud regardless if anyone else is talking, and the client also mumbles in group when others are talking. The nurse determines that the client is experiencing hallucinations. Which action should the nurse take first? A. Respond to the client's feelings rather than the illogical thoughts. B. Identify beliefs and thoughts about what the client is experiencing. C. Provide the client with hope that the voices will eventually go away. D. Ask the client how she has previously managed the voices.

D. Ask the client how she has previously managed the voices. Rationale: The nurse should promote symptom management and determine how the client previously managed the voices. Options A and B are interventions that are useful with clients who are experiencing delusions. Option C is important, but the most important intervention is to promote symptom management.

Which behavior indicates to the nurse that a client with paranoid ideas is improving? A. Arrives on time for all activities. B. Talks more openly about plans to protect his possessions. C. Aggressively uses the punching bag in the gym. D. Discusses his feelings of anxiety with the nurse.

D. Discusses his feelings of anxiety with the nurse. Rationale: Anxious feelings increase paranoid ideation. If the client is able to discuss these feelings, then the client is improving because of fewer paranoid ideas. Option A would indicate that a client with depression or one who is passive-aggressive is improving. Option B indicates feelings of paranoia. Option C indicates the release of anger, and "anger turned inward" is sometimes used as a definition for depression.

The nurse is caring for a client who was admitted after being stabilized for swallowing 10 sleeping tablets. What is the most important question for the nurse to ask? A. "What was the name of the sleeping pills?" B. "Have you ever tied swallowing 10 pills before?" C. "What were you trying to do to yourself?" D. "Do you still feel like harming yourself?"

D. Do you still feel like harming yourself?" Rationale: The priority is to determine the client's intent for self-harm. The name and number of pills is irrelevant to determining if the client remains suicidal. Answer C is a shameful statement and nontherapeutic.

A 27-year-old client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. The client is demanding and active. Which action should the nurse include in this client's plan of care? A. Schedule the client to attend various group activities. B. Reinforce the client's ability to make decisions. C. Encourage the client to identify feelings of anger. D. Provide a structured environment with little stimuli.

D. Provide a structured environment with little stimuli. Rationale: Clients in the manic phase of a bipolar disorder require decreased stimuli and a structured environment. Noncompetitive activities that can be carried out alone should be planned for these clients. Option A is contraindicated because stimuli should be reduced as much as possible. Impulsive decision-making is characteristic of clients with bipolar disorder. To prevent future complications, the nurse should monitor these clients' decisions and assist them in the decision-making process. Option C is more often associated with depression than with bipolar disorder.

A client is admitted with a medical diagnosis of dissociative identity disorder. The nurse will build the client's care plan based on which understanding of the personalities? A. The host personality makes fun with the alternates. B. The alternate personalities are fully aware of each other. C. The host personality ignores the alternate personalities. D. The alternate personalities are aware of the host.

D. The alternate personalities are aware of the host. Rationale: The alternate personalities are aware of the host personality, but the host personality is not aware of the alternate personalities. The nurse needs to build the client's plan of care around this understanding.

The clinic nurse includes in the client's plan of care the number for Al-Anon. Which client will benefit most from this information? A. The daughter whose mother has breast cancer. B. The 16-year-old who uses cocaine 4 to 5 times per week. C. The child of a parent with bipolar disorder. D. The spouse whose partner drinks 5 to 8 mixed drinks per day.

D. The spouse whose partner drinks 5 to 8 mixed drinks per day. Rationale: Al-Anon is a support group for family and friends of alcoholics. Cancer support groups would be best for the daughter of the mother with breast cancer. The support group for the 16-year-old would be narcotics anonymous. A mental health group for children of parents with bipolar disorder would be best for the child.

A client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important? A. Maintain a balanced diet and adequate exercise. B. Be sure that the diet is adequate in salt intake. C. Monitor for any changes in sleep pattern. D. Report any unusual facial movements.

Maintain a balanced diet and adequate exercise. Rationale: Several atypical antipsychotic medications can cause significant weight gain, so the client should be advised to maintain a balanced diet and adequate exercise. Option B is important with lithium, a mood stabilizer. Options C and D are less common than weight gain.

Prior to giving the next dose, notify the health care provider of these symptoms.

The usual activity patterns of each group member