Kahoot MH Hesi
Which symptoms of depression, often overlooked in the older adult client, should the nurse include in the assessment process? Select all that apply. 1) anxiety 2) insomnia 3) weight loss 4) weight gain 5) general fatigue
#2 & 5 Rationale: Insomnia and general fatigue are symptoms of depression that are often overlooked for the older adult client. Anxiety, weight loss and weight gain are all symptoms of depression; however, these symptoms are not often overlooked for the older adult client.
An 80-year-old client with depression requires the prescription of antidepressant drugs. Which tricyclic antidepressant drug is appropriate? 1) doxepin 2) amoxapine 3) nortriptyline 4) trimipramine
#3 Rationale: Nortriptyline and desipramine are preferred for use in the elderly as these antidepressant drugs have less anticholinergic activity. Doxepin, amoxapine, and trimipramine have more cholinergic activity than nortriptyline and are not the preferred drugs for elderly clients.
A school nurse knows that school-aged children often use defense mechanisms to cope with situations that might negatively affect their self-esteem. The nurse hears a child who was not invited to a sleepover say, "I don't have time to go to that sleepover. I have better things to do." The nurse concludes that the student is using which defense mechanism? 1) denial 2) projection 3) regression 5) rationalization
#4 Rationale: Rationalization is the offering of an explanation to one's self or others to allay anxiety. Denial involves avoiding the reality of a situation. Projection is blaming others for one's shortcomings. Regression is returning to an earlier more familiar mode of behavior.
Which medications are used over the long-term to treat generalized anxiety disorder (GAD)? Select all that apply. 1) duloxetine 2) venlafaxine 3) clonazepam 4) escitalopram 5) clomipramine
# 1, 2, 4 Rationale: Duloxetine, venlafaxine, and escitalopram are antidepressants approved for the long-term treatment of generalized anxiety disorder (GAD). Clonazepam is a benzodiazepine used for short-term relief of anxiety; it also induces sedation and can be used to treat panic disorders and anxiety-related depression. Benzodiazepines can be used for short-term management of GAD but are not recommended for long-term therapy. Clomipramine is a tricyclic antidepressant and is used to manage panic disorder and obsessive-compulsive disorder (OCD).
A nurse works in a crisis intervention center. A woman who has experienced sexual abuse comes in and says, "I've got to talk to someone or I'll go crazy. I shouldn't have dated him." What is most important for the nurse to identify after initially assessing the client's physical condition? 1) support system 2) sexual background 3) ability to relay the facts 4) knowledge of sexual assault terminology
#1 Rationale: Identification of a client's support system and relationships is a priority if the victim is to be helped after the immediate crisis is over. Sexual background and ability to relay the facts may eventually be of value, but at this time they are irrelevant in the assessment of the client's current condition and needs. Knowledge of sexual assault terminology is not necessary for care to be provided.
A 10-year-old child who has head lice tells the school nurse, "I'm mad because my mother said I got lice because I don't keep myself clean." What will the nurse say to the child to initiate therapeutic communication about this subject? 1) "It sounds as if you feel that your mother is putting you down." 2) There's no relationship between cleanliness and lice." 3) "You and your mother must be having problems getting along?" 4) "People who don't keep themselves clean are more likely to get lice."
#1 Rationale: Asking whether the child feels put down focuses on the child's perceptions and promotes further communication. Although there is a higher incidence of lice in people with inadequate personal hygiene, in schools and other places where children gather, lice can be transmitted to those with excellent personal care. Asking about the mother-child relationship reads too much into the child's statement and may be too emotionally charged. Although a valid assertion, stating that people who don't keep themselves clean are more likely to get lice is accusatory and discourages further communication.
The primary healthcare provider suspects agranulocytosis in a client with a history of bipolar disorder (BPD). Which drug used to treat BPD is responsible for this condition? 1) clozapine 2) olanzapine 3) risperidone 4) aripiprazole
#1 Rationale: Atypical antipsychotics are generally used to treat clients with bipolar disorder (BPD) to control symptoms during mania and to stabilize mood. Although clozapine is highly effective in treating BPD, this drug is not preferred because it may cause agranulocytosis. Olanzapine is approved for long-term use to prevent the recurrence of mood episodes. Side effects of this drug include weight gain, diabetes, and dyslipidemia. Risperidone along with mood stabilizers such as antiepileptic drugs are used to treat BPD; this drug's side effects include dizziness, somnolence, and fatigue. Aripiprazole is an approved drug for long-term use in clients with BPD. The side effects of aripiprazole include agitation, nervousness, anxiety, and insomnia.
What is a primary consideration for the nurse caring for a client with a history of substance abuse? 1) setting firm, consistent limits and not varying from them 2) using the same type of communication pattern that the client uses 3) avoiding upsetting the client by calling attention to the drug abuse problems 4) realizing that the client will probably need less pain meds than a nonabuser would
#1 Rationale: Setting limits gives structure and balance and demonstrates a caring attitude. The nurse serves as a role model and should use a caring, professional approach with the client. The client must be helped to recognize that a problem with drugs exists. Many substance abusers use multiple drugs, including central nervous system depressants such as alcohol, barbiturates, and antianxiety agents. Opioid abuse is very common. All these drugs lead to cross-tolerance, and the client may need more analgesia than a nonabuser would.
The nurse assesses a client with bipolar disorder. While reviewing the laboratory reports, the nurse finds the client's lithium levels are 1.3 mEq/L (1.3 mmol/L). Which nursing intervention would be appropriate in this client? 1) continuing to administer the drug 2) administering phenothiazine antipsychotics along w/ lithium 3) notify PCP of the levels 4) withdrawing the drug by consulting w PCP
#1 Rationale: The normal range of lithium is below 1.5 mEq/L (1.5 mmol/L). Because the serum lithium level is 1.3 mEq/L (1.3 mmol/L), the nurse should continue administering the drug. Administration of phenothiazine antipsychotics should be avoided because they may cause anticholinergic effects when used with lithium. The primary healthcare provider does not need to be consulted, and the drug should not be withdrawn.
A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? 1) become aware of their personal values 2) gain info related to their needs 3) make correct decisions related to their health 4) alter their value systems to make them more socially acceptable
#1 Rationale: Value clarification is a technique that reveals individuals' values so the individuals become more aware of them and their effect on others. Gaining information, making correct health decisions, and altering value systems to make them more socially acceptable are not outcomes of value clarification.
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, BC 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 Rationale: Consistency, limit-setting, and supportive confrontation are essential nursing interventions designed to provide a secure, therapeutic environment for clients with borderline personality disorder. 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.
An older adult with dementia has recently started to make mistakes regarding the time, place, and person. Which action of the nurse would be appropriate in this situation? 1) minimize environmental stress to reduce confusion 2) let the client continue to think in their own ways 3) prompt the client to recognize the correct date and time 4) ask the client to recall the past to understand the present situation
#2 Rationale: Mistaking the date and time are possible signs of dementia. In this situation, the client would benefit from validation therapy, which involves the adult continuing to think in his or her own way. Minimizing environmental stress can help to reduce confusion, but this is not the appropriate action for the given client's situation. Recognizing the inner needs and feelings of the client is more important than reinforcing the confused older adult's misperceptions. Reminiscence is a therapeutic approach that involves recalling the past to resolve present conflicts.
Which therapeutic communication technique involves using a coping strategy to help the nurse and client adjust to stress? 1) sharing hope 2) sharing humor 3) sharing empathy 4) sharing observations
#2 Rationale: Sharing humor is a therapeutic communication technique that involves using a coping strategy that adds perspective and helps the nurse and client adjust to stress. Nurses should recognize that hope is essential for healing and communicate a sense of possibility. Sharing empathy is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other. Sharing observations often helps a client to communicate without the need for extensive questioning, focusing, or clarification.
A nurse is assessing a client for the use of defense mechanisms. In the presence of which defense mechanism does the client express emotional conflicts through motor, sensory, or somatic disabilities? 1) projection 2) conversion 3) dissociation 4) compensation
#2 Rationale: The defense mechanism is called conversion because the individual reduces emotional anxiety to a physical disability. Projection occurs when people assign their own unacceptable thoughts and feelings to others. With dissociation there is separation of certain mental processes from consciousness as though they belonged to another; a dissociative reaction is expressed as amnesia, fugue, multiple personality, aimless running, depersonalization, sleepwalking, and other behaviors. Compensation is a mechanism used to make up for a lack in one area by emphasizing capabilities in another.
Schizophrenia is associated with both positive and negative symptoms. While assessing a client with schizophrenia, the nurse notes that the client is experiencing positive symptoms; what does the nurse observe that leads to this conclusion? Select all that apply. 1) poverty of speech 2) agitated behavior 3) lack of motivation 4) delusions of grandeur 5) auditory hallucinations
#2 , 4, 5 Rationale: Agitated and restless behaviors are positive symptoms of schizophrenia. A delusion is a fixed false belief that is resistant to reasoning; when a person believes that he or she is a famous, historical or fictional omnipotent character this is called a delusion of grandeur; a delusion is a positive symptom associated with schizophrenia. An auditory hallucination is a sensory perception involving the sense of hearing that occurs in the absence of an external stimulus and is a positive symptom associated with schizophrenia. Decreased verbalization, including a sudden stoppage in the flow of speech (blocking) and lack of inflection, is a negative symptom associated with schizophrenia. Lack of motivation (avolition) and apathy are negative symptoms associated with schizophrenia.
A nurse moves into the working phase of a therapeutic relationship with a depressed client who has a history of suicide attempts. What question should the nurse ask the client when exploring alternative coping strategies? 1) "how have you managed your problems in the past?" 2) "what do you feel that you've learned from this suicide attempt?" 3) "how will you manage the next time your problems start to pilling up?" 4) "were there other things going on in your life that made you want to die?"
#3 Rationale: "How will you manage the next time your problems start piling up?" focuses the interaction toward the future and invites the client to explore alternative coping strategies. "How have you managed your problems in the past?" explores past coping strategies and should have been asked as a part of the initial assessment. "What do you feel that you've learned from this suicide attempt?" is an attempt to explore the client's insight into current coping strategies that should have been made before any discussion of the alternatives. "Were there other things going on in your life that made you want to die?" asks the client once more to ensure that all the precipitating stressors have been identified; this should have been done in the initial assessment.
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 Rationale: 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 profit from their mistakes. These people are too self-centered to have a sense of responsibility to anyone.
What is the priority nursing action for a client with delirium? 1) maintaining skin integrity 2) planning for behavioral interventions 3) creating a calm and safe environment 4) maintaining personal contact through touch
#3 Rationale: The nurse caring for a client with delirium should ensure client safety and ensure a calm and safe environment. The nurse should encourage family members to stay at the bedside along with the client or move the client to the nurses' station to guarantee safety. The client is at a risk for skin breakdown, which is of medium priority. The nurse should ensure the safe environment first, then when it is possible, plan for client-specific behavioral interventions. Reorientation is then followed by contacting the client personally through touching and verbal communication.
A client's severe anxiety and panic are often considered "contagious." What action should be taken when a nurse's personal feelings of anxiety are increasing? 1) refocusing the conversation to more pleasant topics 2) saying to the client, "Calm down. You're making me anxious, too" 3) Saying "Another staff member is coming in. I'll leave and come back later" 4) remaining quiet so personal feelings of anxiety do not become apparent to the client
#3 Rationale: The nurse who is anxious should leave the situation after ensuring continuity of care; the client will be aware of the nurse's anxiety, and the nurse's presence will be nonproductive and nontherapeutic. The client will probably sense the nurse's anxiety through nonverbal channels, if not through verbal responses. Refocusing and asking the client to calm down both meet the nurse's need; this response may make the client feel guilty that something was said that upset the nurse. The client will be aware of the nurse's anxiety, which will increase the client's own anxiety.
During the beginning phase of a therapeutic relationship, why is a clear understanding of participants' roles important? 1) the client should understand what will be discussed 2) the client will know that the nurse is trying to be helpful 3) the client needs to know what to expect from the relationship 4) the client will be able to be prepared for termination of the realtionship
#3 Rationale: This understanding clarifies the settings for the relationship and establishes boundaries. This allows the client to focus on the relationship rather than on roles. An understanding of roles is only one factor among many needed to prepare the client for termination. The nurse being helpful and being prepared for the termination of the relationship are not related to an understanding of roles.
After a week on the mental health unit, a client with the diagnosis of paranoid schizophrenia continues to say, "They're trying to kill me. They all are." What is the best response by the nurse? 1) "we're here to protect you" 2) "no one wants to hurt anyone" 3) "you're having very frightening thoughts" 4) "tell me more about their wanting to kill you"
#3 Rationale: The observation that the client is experiencing frightening thoughts is a reflection of the client's feelings; it leaves the line of communication open. Telling the client that the staff is there to protect the client does not provide security, because the client may believe that the nurse is one of the people plotting. Telling the client that no one wants to hurt anyone discounts the client's thoughts and may increase the agitation. Asking the client to detail the plot supports the client's delusion.
A client is hospitalized with social anxiety disorder. The client has a history of exhibiting intense, irrational fear of being scrutinized by others. Which primary anxiolytic medications would be prescribed to the client? Select all that apply. 1) sertraline 2) paroxetine 3) alprazolam 4) venlafaxine 5) clonazepam
#3 & 5 Rationale: Manifestations of social anxiety disorder include stuttering, sweating, palpitations, dry throat, and muscle tension. Clients with this disorder exhibit intense, irrational fear of being scrutinized by others. Alprazolam and clonazepam are benzodiazepines that are well tolerated in clients, and the benefits are immediate. Sertraline and paroxetine are selective serotonin reuptake inhibitors that are also used in the treatment of social anxiety disorder, but they do not act quickly. Venlafaxine is used to treat posttraumatic stress disorder.
A client asks the nurse, "Because I'm so comfortable talking with you, can we go out for coffee and a movie after I get discharged?" To maintain the boundaries of a therapeutic relationship, how will the nurse respond? 1) "i am flattered, but that would be professionally unethical." 2) "you feel connect to me now; that will changed once you are discharged" 3) "the attention I've been giving you is directed toward getting you better; it isn't social." 4) "A social life is important, so as your nurse let's talk about how you can form friendships"
#4 Rationale: Clients often become socially interested in the nursing staff. When this occurs the nurse should remind the client of the nursing role and take the opportunity to discuss the need for friendships and how to achieve them best. Stating "I'm flattered, but that would be professionally unethical"; "You feel connected to me now; that will change once you are discharged"; and "The attention I've been giving you is directed toward getting you better; it isn't social," although not untrue or inappropriate, do not best address the nursing responsibility in this therapeutic role.
client with dementia and chronic confusion is suspected to have Alzheimer disease. Which imaging technique is specific for Alzheimer disease? 1) difussion imaging (DI) 2) Magnetic resonance imaging (MRI) 3) Magnetic resonance angiography (MRA) 4) Magnetic resonance spectroscopy
#4 Rationale: In diseases such as Alzheimer disease, stroke, and epilepsy, the biochemical process in the brain is altered. Abnormalities in biochemical processes of the brain are diagnosed with magnetic resonance spectroscopy (MRS). Diffusion imaging (DI) is used to evaluate ischemia in the brain to determine the location and severity of a stroke. Magnetic resonance imaging (MRI) involves taking multiple sets of images to determine normal and abnormal anatomy. Magnetic resonance angiography (MRA) is used to evaluate blood flow and blood vessel abnormalities, such as arterial blockage, intracranial aneurysms, and arteriovenous malformations in the brain.
A nurse on a mental health unit has developed a therapeutic relationship with a manipulative, acting-out client. One day as the nurse is leaving, the client says, "Please stay. I'm afraid that the evening staff doesn't like me. They're always punishing me." What is the nurse's most therapeutic response? 1) "I'll ask the staff not to punish you." 2) "tell me more about what you're feeling now" 3) "don't worry. I told you, everything will be all right" 4) "you know I leave at this time. We'll talk about this in the morning"
#4 Rationale: Reminding the client that the nurse leaves at this time each day and telling the client that they will discuss the issue in the morning demonstrates acceptance of the client and sets limits on the client's manipulative behavior. "I'll ask the staff not to punish you" reinforces the client's belief that the evening staff is punishing and could result in a split among the staff members. Asking the client to reveal more about is the current feeling indicates that the nurse has been manipulated by the client. Telling the client not to worry and that everything will be alright is false reassurance; the nurse cannot make everything alright.
The nurse assesses a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis? Select all that apply. 1) passivity 2) fatigue 3) anhedonia 4) grandiosity 5) talkativeness 6) distractibility
#4,5,6 Rationale: Grandiosity, manifested by extravagant, pompous, flamboyant beliefs about the self, frequently occurs during the manic phase of bipolar disorder. As mania increases, the client's rate of speech increases, and speech is delivered with urgency (pressured speech). Clients experiencing manic episodes have difficulty blocking out incoming stimuli, which results in distractibility and responses to irrelevant stimuli. Passiveness is exhibited when clients turn anger inward and show little emotion. It frequently occurs during the depressive stage of bipolar disorder. Fatigue is associated with the depressive stage of bipolar disorder. Anhedonia, an inability to feel pleasure, is associated with the depressive stage of bipolar disorder.