Mental 3
A nurse is assessing a client who has borderline personality disorder (BPD). Which should be given priority during the assessment? A.Nutrition patterns B.Personal hygiene practices C.Physical functioning D.Somatic issues
A.Nutrition patterns
The nurse is caring for a client that states, "Everyone would be better off if I just drove off the bridge into the ocean!" Which question will the nurse ask to determine the intent to die? A."Can you tell me how serious you are about dying?" B."How often do you have this thought?" C."Is this thought increasing in frequency?" D."Have you done anything to put your plan into action?"
A."Can you tell me how serious you are about dying?"
The nurse is evaluating the effectiveness of the antipsychotic medication a client is taking for the treatment of schizophrenia. Which question(s) will be of most benefit to determine the effectiveness? Select all that apply. A."Have the symptoms you were experiencing disappeared?" B."Are you able to carry out your daily life despite the persistence of some psychotic symptoms?" C."Are you committed to taking the medication as prescribed?" D."Are you satisfied with your quality of life?" E."Do you have access to community agencies that will help you to live successfully in this community?"
A."Have the symptoms you were experiencing disappeared?" B."Are you able to carry out your daily life despite the persistence of some psychotic symptoms?" C."Are you committed to taking the medication as prescribed?" D."Are you satisfied with your quality of life?"
The nurse is leading a family therapy group with a client addicted to alcohol. Which statement made by the spouse indicates the need for additional education regarding alcoholism as a family illness? A."I have to call in sick for the client when the client is too hung over to go to work." B."Last time the client got arrested, I just let the client sit in jail." C."We have separated our finances so that I will not go broke." D."I take my kids with me to Al-anon meetings every week."
A."I have to call in sick for the client when the client is too hung over to go to work."
The nurse provides medication teaching to a client who is newly prescribed a serotonin norepinephrine reuptake inhibitor (SNRI) for the treatment of depression. Which client statement indicates a need for additional teaching? A."I might experience an increased appetite." B."I can use sugar-free gum to treat dry mouth." C."I should wear sunscreen due to photosensitivity." D."I should change positions slowly to decrease my risk for falls."
A."I might experience an increased appetite."
While caring for a client with anorexia nervosa, a nurse anticipates that the client would have difficulty making which comment(s)? Select all that apply. A."I'm mad at you because you won't let me go on a pass unless I gain weight." B."I need to have everything in its place and perfect." C."If I gain a pound, I'll just keep gaining weight." D."I am very involved in preparing my food and counting calories." E."I saw that client looking at me; they need to mind their own business."
A."I'm mad at you because you won't let me go on a pass unless I gain weight." E."I saw that client looking at me; they need to mind their own business."
The nurse is caring for a client who has has been inhaling solvents to receive a "high." After the nurse provides education on the effects of inhaling solvents, which statement from the client indicates understanding of the teaching? A."Inhalants are central nervous system (CNS) depressants similar to alcohol." B."The 'high' that I am getting is from hallucinogenic properties in the inhalant." C."Inhalants are easy to come by and highly addictive." D."When inhaling solvents, I get an instant CNS stimulation that is euphoric."
A."Inhalants are central nervous system (CNS) depressants similar to alcohol."
A client calls the emergency department of the local hospital reporting that after 16 years of heavy drinking, the client is tired and wants to quit "cold turkey." Which is the best response by the nurse? A."It is not safe to stop drinking suddenly without medicine. Please let us help you." B."You sound really motivated. Come in and we will help you find a treatment center." C."After a few days of rest, you should feel much better as long as you do not drink anything." D."You will likely feel anxious and get a severe headache. Treat these symptoms with acetaminophen and rest, and come in if they do not get better in 3 to 5 days."
A."It is not safe to stop drinking suddenly without medicine. Please let us help you."
A client who has a history of displaying passive aggressive behavior has a pattern of being late for counseling appointments or cancelling at the last minute. As a result, the counselor has set a limit with the client specifying that the client will forfeit the appointment if the client is more than 5 minutes late for an appointment. Today, the client has come to the counselor's office more than 10 minutes late, at which point the counselor has reminded the client of this limit. Which response would be most consistent with this client's diagnosis? A."Oh my gosh, I'm so sorry but it totally wasn't my fault because traffic was a complete nightmare." B."You're still getting paid for this appointment so what difference does it make?" C."I apologize completely and this time I really promise that it will never happen again." D."Whatever. No skin off my back."
A."Oh my gosh, I'm so sorry but it totally wasn't my fault because traffic was a complete nightmare."
A client who is experiencing mania states, "What time is it? I have to see the doctor. Is breakfast here yet? I've got to see the doctor first. Can I get my cereal out of the kitchen?" Which response by the nurse would be most appropriate? A."Please speak slowly. I'm not sure what you need first." B."You will have to be quiet and have breakfast after the doctor comes." C."Are you hungry?" D."Why are your thoughts racing this morning?"
A."Please speak slowly. I'm not sure what you need first."
The nurse expects psychiatric hospitalization for which of the clients diagnosed with schizoaffective disorder experiencing delusional thoughts? Select all that apply. A.A 76-year-old person whose symptoms are acute in nature B.A 25-year-old person who is having a first delusional experience C.A 45-year-old person who was arrested for assaulting a policeman D.A 30-year-old person who also has a diagnosis of depression E.A 39-year-old person who reports minor side effects from the current medication
A.A 76-year-old person whose symptoms are acute in nature B.A 25-year-old person who is having a first delusional experience C.A 45-year-old person who was arrested for assaulting a policeman D.A 30-year-old person who also has a diagnosis of depression
A client who has an eating disorder is becoming dependent on the nurse for direction in food choices. Which approach by the nurse would be most therapeutic? A.Approach the client with an adult-like objectivity. B.Give the support and direction that the client is seeking. C.Give approval for positive changes seen in the client. D.Take care of the needs that the client is neglecting.
A.Approach the client with an adult-like objectivity.
The nurse is caring for a client diagnosed with bulimia. Which would be important for the nurse to do first? A.Ask the client directly about thoughts of suicide or self-harm B.Identify the cues related to binging C.Control the eating responses D.Provide small regular meals and snacks
A.Ask the client directly about thoughts of suicide or self-harm
A nurse is preparing a presentation for a local middle school health class about eating disorders as a means for prevention and early detection. Which characteristic would the nurse incorporate into the presentation as being common to both anorexia nervosa and bulimia nervosa? Select all that apply. A.Body dissatisfaction B.Feelings of control C.Obsessiveness D.Boundary problems E.Sexuality fears F.Cognitive distortions
A.Body dissatisfaction C.Obsessiveness F.Cognitive distortions
The nurse is teaching a group of adults in a community outreach clinic about the eating disorder bulimia nervosa. Which element(s) will the nurse include in the teaching? Select all that apply. A.Clients are typically of normal weight. B.Clients refrain from compensatory methods. C.The client perceives that binge eating is abnormal. D.Feelings of guilt do not occur after binging. E.Clients feel in control when binge eating.
A.Clients are typically of normal weight. B.Clients refrain from compensatory methods. C.The client perceives that binge eating is abnormal.
The nurse is working with clients with personality disorders that are having problems with relationships and other parts of their life. Which barrier(s) are the nurse experiencing when working with this group of clients? Select all that apply. A.Clients fail to understand the need to change their behavior. B.There is a slow progress and clients stop seeking help for issues. C.It is difficult to change personality traits since they are deeply embedded. D.The clients may take pride in some of the personality traits they have. E.Clients with personality disorders are always receptive to treatment.
A.Clients fail to understand the need to change their behavior.
A group of nursing students is reviewing the similarities and differences between bulimia nervosa and binge eating disorder (BED). The students demonstrate understanding when they identify which characteristic(s) as specific to BED? Select all that apply. A.Clients typically are obese. B.Clients refrain from purging behaviors. C.Binge eating periods are shorter. D.Clients engage in overexercising. E.Feelings of guilt do not occur after binging.
A.Clients typically are obese. B.Clients refrain from purging behaviors.
Despite being admitted to the hospital yesterday for the treatment of complications of anorexia nervosa, a 19-year-old client continues to have only bites of food and small sips of fluids. Which of the following nursing diagnoses is paramount in this client's care? A.Deficient fluid volume related to inability to meet bodily fluid requirements B.Impaired social interaction related to aggressive behavior C.Anxiety related to inadequate coping mechanisms D.Imbalanced nutrition less than body requirements related to refusal to eat
A.Deficient fluid volume related to inability to meet bodily fluid requirements
Based on psychological theories, which is believed to be critical to understanding personality disorder? A.Difficult temperament B.Chaotic families C.Abuse D.Functional attachments
A.Difficult temperament
The nurse is providing care to a client diagnosed with anorexia and notes that the client demonstrates behaviors that reflect an intense physical and emotional process that overrides all physiologic body cues. Which term would the nurse use to document this finding? A.Drive for thinness B.Body image distortion C.Interoceptive awareness D.Perfectionism
A.Drive for thinness
When preparing to educate a client regarding a newly prescribed antipsychotic medication, which action would be most appropriate for the nurse to do? Select all that apply. A.Encourage the use of sugar-free gum to help manage dry mouth B.Suggest methods to minimize the potential for weight gain C.Identify lifestyle adjustments that the resulting lethargy may require D.Advise the client to discuss any concerns regarding sexual dysfunction E.Discuss the increased difficulty the medication has on conception for both genders
A.Encourage the use of sugar-free gum to help manage dry mouth B.Suggest methods to minimize the potential for weight gain C.Identify lifestyle adjustments that the resulting lethargy may require D.Advise the client to discuss any concerns regarding sexual dysfunction
The nurse is performing the initial assessment of a client diagnosed with schizophrenia. What should be the nurse's approach while assessing this client? Select all that apply. A.Engage in a one-to-one interaction with the client B.Provide effective physical care C.Perform diagnostic testing D.Expect the client will have cognitive deficits E.Establish a therapeutic relationship
A.Engage in a one-to-one interaction with the client E.Establish a therapeutic relationship
The nurse suspects that a client taking an antipsychotic medication for the treatment of schizophrenia is having drug-induced parkinsonism. Which finding(s) assessed by the nurse will correlate with this disorder? Select all that apply. A.Facial expressions are mask-like with little emotion observed. B.The fingers are making a pill rolling motion. C.The client is having drooling from the side of the mouth. D.The client has a resting heart rate of 102 beats per minute. E.The client demonstrates a slowness and difficulty initiating movements.
A.Facial expressions are mask-like with little emotion observed. B.The fingers are making a pill rolling motion. C.The client is having drooling from the side of the mouth. E.The client demonstrates a slowness and difficulty initiating movements.
The nurse is caring for a client that delivered a newborn 2 days previously and states that the client is having crying spells, anxiety, and sadness that started the day after delivery. Which is the most therapeutic action by the nurse? A.Inform the client that these symptoms will go away and to seek support from friends and family. B.Refer the client to a psychiatrist since it is important to get treatment for postpartum depression quickly. C.Prepare for the administration of an IV neuroactive steroid over a 60-hour period of time. D.Discuss with the client the potential for involuntary admission to prevent harm to self and newborn.
A.Inform the client that these symptoms will go away and to seek support from friends and family.
A client is brought to the emergency department by a friend with reports of confusion and vomiting after using cocaine. The heart rate is 146 beats per minute, BP 200/140 mm Hg, and pupils are dilated. Which is the necessary action(s) by the nurse? Select all that apply. A.Maintain a safe environment for the client. B.Monitor heart rate and blood pressure frequently. C.Administer a calcium channel blocker to lower blood pressure and heart rate. D.Administer naloxone IV. E.Administer haloperidol IV.
A.Maintain a safe environment for the client. B.Monitor heart rate and blood pressure frequently.
A client is admitted to the detoxication unit on Sunday evening. The client discloses that the client's last alcoholic drink was just before the client was admitted to the unit. When can the nurse expect that the client's alcohol withdrawal symptoms will begin? A.Monday morning B.Tuesday evening C.Wednesday morning D.Friday evening
A.Monday morning
A client is being treated for bipolar disorder and the health care provider has ordered milieu therapy. What best practice method should the nurse use? A.Place the client in a private room away from the nurse's station. B.Arrange for the client to attend group activity sessions. C.Make sure that the client has access to both phone and television. D.Stress the importance of participating in group sessions.
A.Place the client in a private room away from the nurse's station.
The psychiatric nurse expects similar experiences among all clients diagnosed with a Cluster A personality disorder related to ... A.interpersonal relationships. B.tendency to be distrustful. C.lack of employable skills. D.episodic manic behavior.
A.interpersonal relationships.
A nurse is conducting an inservice program on personality disorders. When describing obsessive-compulsive personality disorder, which characteristic(s) would the nurse most likely include? Select all that apply. A.Preoccupation with control B.Inability to delay rewards C.Strict attention to rules D.Difficulty with decision making E.Relationships primarily formal and polite
A.Preoccupation with control C.Strict attention to rules D.Difficulty with decision making E.Relationships primarily formal and polite
A nurse is preparing a training plan for a group of new nurses about antisocial personality disorder. Which terms would the nurse include as words used to describe the behaviors associated with this condition? Select all that apply. A.Psychopath B.Manipulator C.Criminality D.Sociopath E.Psychotic
A.Psychopath D.Sociopath
The nurse is caring for a client with a substance use disorder. Which action(s) would the nurse include when teaching the family on ways to support the client? Select all that apply. A.Set realistic goals. B.Focus on future plans. C.Promote coping skills. D.Practice different situations with role-play. E.Apply ways to decrease codependency between family members.
A.Set realistic goals. C.Promote coping skills. D.Practice different situations with role-play. E.Apply ways to decrease codependency between family members.
The psychiatric nurse managing the care of a client experiencing alcohol withdrawal instructs unit staff to anticipate that the client may experience which neurological response? A.Tactile hallucinations B.Gustatory hallucinations C.Somatic delusions D.Nihilistic delusions
A.Tactile hallucinations
The nurse is counseling a group of clients recovering from substance abuse about the nature of denial. Which intervention should the nurse teach the clients to use to help them gain insight into their denial? A.Teach them to question why they feel threatened. B.Teach them meditation techniques. C.Teach them alternative coping strategies. D.Teach them to have realistic expectations about themselves.
A.Teach them to question why they feel threatened.
The nurse is creating a plan of care for a client diagnosed with bulimia nervosa that has just been admitted. Which immediate outcome(s) will the nurse assign for evaluation of effective care? Select all that apply. A.The client will be free from self-inflicted harm to self. B.The client will begin keeping a journal to deal with stress. C.The client will express feelings in a non-food related way. D.The client will verbalize feelings of guilt, anxiety, or anger within 4 days. E.The client will verbalize a realistic body image.
A.The client will be free from self-inflicted harm to self. B.The client will begin keeping a journal to deal with stress. D.The client will verbalize feelings of guilt, anxiety, or anger within 4 days.
The nurse suspects another nurse of substance use disorder while working in the long-term care facility. Which behavior(s) will the observing nurse report to the nurse manager? Select all that apply. A.The clients are reporting a lack of pain control when the nurse is working. B.The nurse administers narcotics and then goes to use the bathroom. C.The observing nurse finds oral narcotics blister packs torn in the back. D.The narcotic count is incorrect when the nurse ends the shift. E.The nurse has poor hygiene practices and has an offensive body odor.
A.The clients are reporting a lack of pain control when the nurse is working. B.The nurse administers narcotics and then goes to use the bathroom. C.The observing nurse finds oral narcotics blister packs torn in the back. D.The narcotic count is incorrect when the nurse ends the shift.
According to the immunovirological theory, a person is at risk for developing schizophrenia when which factors were present while the person's was in utero? Select all that apply. A.The mother had the influenza virus while pregnant B.The mother resided in a crowded urban city while pregnant C.The mother had a sexually transmitted disease while pregnant D.The birth required the use of forceps or vaccum E.The mother took larger doses of folic acid prenatally
A.The mother had the influenza virus while pregnant B.The mother resided in a crowded urban city while pregnant C.The mother had a sexually transmitted disease while pregnant
When assessing a client with a delusional disorder who is experiencing somatic delusions, which would the nurse expect as within normal parameters? Select all that apply. A.Thinking B.Orientation C.Self-care patterns D.Attention E.Sleep patterns
A.Thinking B.Orientation D.Attention
A client is being screened for clinical symptoms related to depression over the past 2 weeks. Which self-assessment screening instruments would be most appropriate? A.Zung Self-Assessment Scale B.Beck Depression Inventory C.Hamilton Rating Scale for Depression D.Geriatric Depression Scale
A.Zung Self-Assessment Scale
The nurse is screening clients in the community for major depressive disorder (MDD). Which client has the greatest risk for developing MDD? A.a young adult White female client with a family history of depressive disorder B.a young adult male client of Hispanic heritage with a current diagnosis of substance use disorder C.an older adult female client of African descent with a personal history of depression D.an older adult male client of Native American/First Nations heritage who is diagnosed with diabetes mellitus
A.a young adult White female client with a family history of depressive disorder
A client has been brought to the emergency department following a syncopal episode at home. The nurse notes the client's hair and nails are brittle and easily broken. What does the nurse suspect is the cause? Select all that apply. A.an eating disorder B.a diet high in sodium C.childhood respiratory illness D.lack of essential nutrients E.hormone insufficiency
A.an eating disorder D.lack of essential nutrien
A client has been brought to the emergency room by the police after they were trying to walk down a six-lane interstate highway. Witnesses state the client was seen smoking marijuana a few hours earlier at a park nearby. Which element(s) will the nurse likely find during assessment? A.conjunctival redness B.increased heart rate C.reports of dry mouth D.request for food E.impaired long-term memory
A.conjunctival redness B.increased heart rate C.reports of dry mouth D.request for food
An outpatient client has expressed skipping meals and losing weight intentionally to "fit in" with their friends. Which psychological symptom(s) are correlated with anorexia nervosa that the nurse should assess? Select all that apply. A.emotional dysregulation B.perfectionism C.impulsivity D.ritualistic behaviors E.boundary problems F.limit-setting difficulties
A.emotional dysregulation B.perfectionism D.ritualistic behaviors
The client has been brought to the emergency department. The client's appearance is unkempt and their shoes do not match. The nurse has seen this client before and knows the client has a history of alcohol use disorder, homelessness, and no family. What element(s) should the nurse also consider as possibly ingested by this client? Select all that apply. A.mouthwash B.cologne C.rubbing alcohol D.paint thinner E.turpentine
A.mouthwash B.cologne C.rubbing alcohol
The nurse is caring for a client who has an acute intoxication of cocaine. Which assessment finding(s) will the nurse most likely find? Select all that apply. A.oral temperature of 38°C B.pinpoint pupils C.2+ pitting edema D.heart rate 58 E.moist skin
A.oral temperature of 38°C E.moist skin
A client is being assessed in the clinic with an intense fear of gaining weight. The nurse's assessment reveals the client eats normal amounts of food at times and then purges to maintain thinness. Which eating disorder does the nurse identify in the client? A.purging disorder B.bulimia nervosa C.binge eating disorder D.anorexia nervosa
A.purging disorder
A client recovering from a substance use disorder reports feelings of anxiety. Which activity(ies) would the nurse recommend to help relieve the client's stress? Select all that apply. A.relaxing B.exercise C.listen to music D.learn a new activity E.meet up with old friends
A.relaxing B.exercise C.listen to music D.learn a new activity
The nurse is caring for a client who routinely uses heroin. Which symptom(s) indicates to the nurse that the client is withdrawing from the substance? Select all that apply. A.yawning B.sweating C.rhinorrhea D.lacrimation E.abdominal pain
A.yawning B.sweating C.rhinorrhea D.lacrimation
The nurse in the outpatient mental health clinic is caring for a 13-year-old male client who presents with alterations in behavior and emotional outburst. At 1515, the nurse is reviewing the medical chart and reviews the Nurse's Notes from 1500. The nurse discusses the plan of care with the health care provider.
Actions To Take A.Determine the level of family accommidation.* B.Perform a strength assessment Potential Conditions A.obsessive-compulsive disorder* Parameters to Monitor A.familty participation in symptom management* B.response to selective serotonin reuptake inhibitor (SSRI) therapy*
The nurse is providing an educational session with a client and spouse on ways to support the client with a diagnosis of an eating disorder who is returning to the home after participating in a day treatment program. The nurse considers the client's and spouse's statement and reviews the medical history and prescriptions when considering how best to respond to the spouse's statement.
Actions To Take A.Encourage the spouse to consider how the client might be feeling before meals.* B.Provide practices on sharing emotions around eating.* Potential Conditions A.alexithymia Parameters to Monitor A.parameters of client's physical condition B.journal notes on emotions felt associated with food*
The nurse is caring for a 25-year-old male client in the outpatient community clinic. The client reports difficulty sleeping for the previous month. The nurse and health care provider are meeting to discuss the client's sleep diary for the previous week.
Actions To Take A.Perform a sleep history.* B.Review the medication list. Potential Conditions A.acute insomnia* Parameters to Monitor A.perception of sleep quality B.wake after sleep-onset pattern*
The nurse is caring for a 36-year-old male client brought to the emergency department with somnolence and depressed respiratory and blood pressure values. The nurse is discussing the client's presentation and their treatment plan with the health care provider.
Actions To Take A.Prepare to administer naloxone.* B.Stay with the client.* Potential Conditions A.opioid overdose* Parameters to Monitor A.vital signs every 5 minutes* B.level of arousal*
The nurse in the inpatient psychiatric hospital is caring for a 16 year old male client admitted for exacerbation of anorexia nervosa. The nurse is reviewing Nurse's Notes and laboratory values and is discussing the plan of care with the health care provider.
Actions To Take A.Replace electrolytes via the intravenous (IV) route.* B.Limit movement by having the client* Potential Conditions A.refeeding syndrome Parameters to Monitor A.electrolyte levels* B.cardiac status
The nurse is caring for an older adult client with mild cognitive impairment and their spouse in the outpatient community health clinic.The couple states, "We don't know what is happening and we are both getting frustrated." The spouse asks the nurse, "What should I do?"
Actions To Take A.Teach the spouse to help the client using simple, positive verbal cues about completing the task.* B.Teach the couple about the symptoms.* Potential Conditions A.apraxia* Parameters to Monitor A.demonstration of tasks B.practicing cueing the client*
A nurse is working with the parents of a teenager who is displaying behaviors of anti-social personality disorder (ASPD). After diagnosis has been confirmed and teaching of the disorder has been completed, which statement by the parents indicates that they have understood the information? A."We understand that our child is being diagnosed with ASPD, and they are only 16 years old." B."Because our child displayed aggression toward animals in their early teens, we now see they have developed ASPD." C."Our child will likely develop adult ASPD since they were diagnosed with ADHD at age 10." D."Our child needs to explain why this behavior is only seen when they are out drinking with buddies." E."Our child is diagnosed with ASPD because of aggression and won't follow the rules."
B."Because our child displayed aggression toward animals in their early teens, we now see they have developed ASPD." C."Our child will likely develop adult ASPD since they were diagnosed with ADHD at age 10."
The nurse is interviewing a client with alcohol use disorder. Which client statement would alert the nurse that the client is not coping with their addiction? A."Often I wake up and don't know how I got there or where I am." B."I appreciate the help I'm getting and now I can stop drinking on my own." C."I'm usually happy go lucky but when I drink I get aggressive and angry." D."I have lots of friends that drink a lot more than I do and they have lost their jobs."
B."I appreciate the help I'm getting and now I can stop drinking on my own."
The nurse is assessing a client with anorexia nervosa. Which statement(s) by the client will likely support this diagnosis? Select all that apply. A."I don't know what the fuss is about, I'm too fat to be a model." B."I know some friends; I just don't hang out or talk to them." C."We have a really tight-knit family, always laughing." D."When I graduate, I'm going to college to be a lawyer." E."There are a lot of thin people in my family."
B."I know some friends; I just don't hang out or talk to them."
A client is prescribed disulfiram as part of the alcohol treatment program to prevent relapse. The client asks a nurse, "How will this drug help me?" Which response by a nurse would be most appropriate? A."It will help to cure your alcoholism." B."It can help to prevent you from drinking." C."It makes the withdrawal symptoms less troublesome." D."It helps to clear the alcohol out of your body."
B."It can help to prevent you from drinking."
The nurse provides education to a client's family about the client's eating disorder, anorexia nervosa. Which statement would indicate that the education was effective? A."We will eat our evening meals together with no exceptions." B."We will negotiate resolutions to family conflicts." C."We will spend less time discussing troublesome family members." D."We will give the client frequent encouragement for eating well and maintaining the client's weight."
B."We will negotiate resolutions to family conflicts."
The parents of a young adult who has schizophrenia ask how they can recognize when their child is beginning to relapse. Which will the nurse educate the parents about which to assess for? Select all that apply. A.Excessive sleeping B.Fatigue C.Irritability D.Increased inhibition E.Negativity
B.Fatigue C.Irritability E.Negativity
A client diagnosed with bipolar disorder has a history of multiple episodes and states, "I'm so frustrated with what's happened because of these episodes." Which technique should a nurse encourage to help support this client's recovery? A.Codependence B.Highlight hope C.Self-control D.Independent decision-making
B.Highlight hope
A nurse is implementing a brief intervention with a client who is abusing alcohol. What action will the nurse perform? A.Asking the client questions about alcohol use B.Negotiating a conversation with the client about the need to change C.Pointing out the inconsistencies in thoughts, feelings, and actions D.Helping the client change the way the client thinks about a situation
B.Negotiating a conversation with the client about the need to change
The nurse is creating a plan of care for a client with anorexia nervosa. Which nursing intervention is most likely to help the client to establish healthy eating patterns? A.Leave the client alone to relax during meals. B.Offer liquid protein supplements if the client is unable to complete a meal. C.Observe the client for 30 minutes after all meals. D.Weigh the client weekly in the same clothing at the same time of day.
B.Offer liquid protein supplements if the client is unable to complete a meal.
The nurse working in the emergency department reviews the medical record for a 58-year-old male client presenting with intractable vomiting x 12 hours. Which nursing intervention will the nurse prioritize? A.Elevate the head of bed. B.Pad the side rails. C.Dim the lights. D.Monitor urine output.
B.Pad the side rails.
A client is brought to the emergency department after having overdosed on cocaine. When assessing the client, which condition(s) would a nurse document as evidence of cocaine overdose? Select all that apply. A.Euphoria B.Seizures C.Cardiac arrhythmia D.Paranoia E.Insomnia
B.Seizures C.Cardiac arrhythmia
A nurse who started recovering from alcohol abuse 3 months earlier is ready to return to work. When speaking with the therapist, the nurse states the nurse is nervous about how coworkers will respond to the nurse now that "they all know I'm a drunk." Which diagnosis best targets the problem implicit in the nurse's remarks? A.Anxiety related to situational crisis B.Situational low self-esteem related to medical condition C.Ineffective coping related to long history of alcohol use D.Powerlessness related to perceived inability to change the opinions of others
B.Situational low self-esteem related to medical condition
A 16-year-old with anorexia nervosa is admitted to the unit. Which is the most appropriate short-term outcome? A.The client will accept the self as having value and worth. B.The client will admit the client has a fear of gaining weight. C.The client will follow a nutritionally balanced diet for the client's age. D.The client will identify problems and potential alternative coping strategies.
B.The client will admit the client has a fear of gaining weight.
A client with an eating disorder has not received treatment in the past and now identifies that they need help but has limited ability to travel for health care. When the client inquiries about the ability to be helped via telehealth, which will the telehealth nurse inform the client? A.Although this is not an optimal treatment option, it will suffice since the client cannot travel for health care. B.This option incorporates evidence-based practices and has positive treatment outcomes. C.It will be difficult to monitor a client's progress through telehealth visits such as weight. D.The client will be unable to be prescribed medications through a telehealth visit if needed.
B.This option incorporates evidence-based practices and has positive treatment outcomes.
The nurse is caring for a client with an eating disorder and is questioning the client to obtain subjective data. How should the nurse approach questioning the client? Select all that apply. A.a direct, firm approach B.a nonjudgmental manner C.nonconfrontational questions D.questioning regarding peers E.using blocking statements
B.a nonjudgmental manner C.nonconfrontational questions
An adolescent reports smoking marijuana with friends during lunch time at school and taking a parent's opioid pain medication "to get high." Which factor(s) would the nurse expect to assess about the client's environment? Select all that apply. A.rural area B.high crime rates C.single-parent home D.high unemployment E.substandard school systems
B.high crime rates D.high unemployment E.substandard school systems
A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to the client's feelings of sadness and hopelessness, the nurse would likely assess which physiologic symptoms of depression? A.Anxiety, unconscious anger, and hostility B.Guilt, indecisiveness, and poor self-concept C.Psychomotor retardation and poor appetite D.Meticulous attention to grooming and hygiene
C.Psychomotor retardation and poor appetite
A client being counseled for depression reveals that they would like to develop a sense of connection and belonging within a support system. Which wellness strategy would be encouraged by the nurse for the client? A."Educate yourself about depression or join a support group." B."Pray, meditate, help others, or volunteer." C."Contact at least one friend or attend a religious service." D."Avoid being a perfectionist, consider a massage or meditation."
C."Contact at least one friend or attend a religious service."
A client has been purging to maintain weight loss. Which would be an important goal immediate for this client? A.Understanding that purging is an ineffective means of weight control B.Recognizing that purging promotes binge eating C.Being free of self-inflicted harm D.Using distraction to stop the urge to purge
C.Being free of self-inflicted harm
A group of nursing students are studying bipolar disorder. What client information would suggest social rhythm disruption theory as the cause? A.Client reports increased stress. B.Client reports they do not experience much stress prior to episodes. C.Client states that they are a "night person." D.Client prefers to take things as they come.
C.Client states that they are a "night person."
A nurse is giving a presentation on mental health promotion at a community center. A participant states, "My friend tells me I'm depressed because I don't have a lot of energy and have trouble concentrating. I had to quit my full-time job because I don't seem to have the energy to manage it. But I don't want to kill myself or anything like that." Although more data are needed for diagnosis, the nurse suspects that the client may have what? A.Bipolar II disorder B.Cyclothymic disorder C.Dysthymic disorder D.Major depressive disorder
C.Dysthymic disorder
A nurse is assessing a client with bipolar disorder who is experiencing mania. The client states, "I'm just so beautiful. Everyone just stops and stares at how gorgeous I am. People constantly want to have sex with me." The nurse interprets these statements as indicative of which type of mood? A.Irritable B.Elevated C.Expansive D.Euphoric
C.Expansive
A client is being treated for chronic alcohol use disorder. A nurse notes the client is wearing a stethoscope, and asks the client where the stethoscope came from. The client gives a rambling response that the nurse knows is not accurate. The nurse suspects that the client may be experiencing which condition(s)? Select all that apply. A.Wernicke syndrome B.delirium tremens C.Korsakoff amnestic syndrome D.malignant hyperthermia E.alcohol withdrawal syndrome
C.Korsakoff amnestic syndrome
The nurse is planning the care of a client with bipolar disorder and addiction to heroin that is in a rehabilitation facility. Which outcome(s) will the nurse assign in the immediate phase after withdrawal symptoms are over? Select all that apply. A.The client will initiate interactions with at least two other people in the facility. B.The client will assess strengths and weaknesses realistically. C.The client will share feelings openly within 48 hours. D.The client will receive only prescribed medications. E.The client will verbalize plans to join a community support group.
C.The client will share feelings openly within 48 hours. D.The client will receive only prescribed medications.
A client with a history of opioid use disorder is exhibiting manifestations of moderate withdrawal. Which assessment finding(s) will the nurse document as evidence of moderate withdrawal? Select all that apply. A.rhinorrhea B.lacrimation C.dilated pupils D.dysphoria E.muscle aches
C.dilated pupils E.muscle aches
The nurse is interviewing an 18-year-old client about eating behaviors. The client's parents have brought the client to treatment because the client's mother suspects that the client has been binge eating and vomiting. The nurse asks the client if the client ever feels that the client cannot control the client's eating. The client's mother states, "I know the client can't control it; the client ate an entire cake last night!" Which comment by the nurse is best? A."I see. What are your thoughts on what your mother has said?" B."Do you often have to answer for your child?" C." Is what your mother said true?" D."I see. Do you ever feel as though you cannot control your eating?"
D."I see. Do you ever feel as though you cannot control your eating?"
An adolescent diagnosed with anorexia nervosa is insistent on being allowed to take a laxative. Which response by the nurse best demonstrates the management of this client request? A."Using laxatives is bad for you because your electrolytes can become unbalanced." B."Using a laxative to purge is not an acceptable way to manage your weight." C."Why do you want to take a laxative?" D."Laxatives are not a part of your treatment plan."
D."Laxatives are not a part of your treatment plan."
A client with bulimia nervosa is being treated at an outpatient clinic and is prescribed a selective serotonin reuptake inhibitor (SSRI). Which instruction(s) would a nurse include when teaching the client about the prescribed medication? Select all that apply. A."Closely monitor your fluid intake while taking this medication." B."Stop taking this medication if it causes weight gain." C."Expect menstrual irregularities, particularly if they've occurred previously." D.Note that the drug may take up to 4 weeks to get a full effect." E."This medication may cause drowsiness or dizziness."
D."Note that the drug may take up to 4 weeks to get a full effect." E."This medication may cause drowsiness or dizziness."
The nurse is talking with the parent of an adolescent with anorexia nervosa about how they interact at home. Which response(s) by the parent related to the history of the disorder correlates with anorexia? Select all that apply. A."We found that our child was having a problem with stealing." B."My child has a history over the last 2 years of cocaine use disorder." C."My child will be graduating high school 2 years earlier than others." D."You should see all of the achievements my child has and trophies." E."My child has always been so "good" before the onset of the illness."
D."You should see all of the achievements my child has and trophies." E."My child has always been so "good" before the onset of the illness."
A client diagnosed with anorexia nervosa is being treated in an outpatient setting in the community. Which activity would be the priority? A.Improving nutritional status B.Acknowledging the severity of the illness C.Confirming beliefs about body size D.Establishing a therapeutic relationship
D.Establishing a therapeutic relationship
27 The nurse is caring for a client with opioid addiction who is on a methadone treatment plan. Which statement about methadone does the nurse understand is the reason it is used for opioid detoxification? A.It is not physiologically addicting. B.It is similar to an opioid but in a different drug class. C.It can be given and monitored once per week. D.It has a long half-life.
D.It has a long half-life.
The client with bulimia reports feeling helpless and says, "What's the use?" As the nurse plans the client's care, the priority diagnosis is which? A.Ineffective individual coping B.Anxiety C.Nutrition that is less than body requirements D.Risk for self-directed violence
D.Risk for self-directed violence
When developing the plan of care for a client with borderline personality disorder (BPD), which areas would the nurse identify as likely problematic? Select all that apply. A.Hydration B.Self-care C.Pain D.Sleep E.Nutrition F.Self-harm
D.Sleep E.Nutrition F.Self-harm
A nurse is preparing an educational session for family members affected by substance abuse. Which point should the nurse include in the session? Select all that apply. A.Families can expect the client to seek treatment independently upon relapse. B.It is possible to refrain from substance abuse through personal motivation. C.Beer and wine are less problematic in substance abuse. D.Substance abuse is an illness like any other. E.An individual with substance abuse issues typically cannot use drugs socially.
D.Substance abuse is an illness like any other. E.An individual with substance abuse issues typically cannot use drugs socially.
The nurse is performing an assessment of the family dynamics for a client with an eating disorder. Which issue observed by the nurse is an indicator of why the client may be experiencing an eating disorder? A.There are multiple siblings in the household. B.The family appears to lack interest in the client. C.The client has supportive and encouraging relationships. D.The client has overprotective parents.
D.The client has overprotective parents.
A nurse is reviewing the medical records of several clients being treated for eating disorders at the community mental health center. Which behavior would the nurse identify as differentiating a client who is believed to have bulimia nervosa from one who has anorexia nervosa? A.The client is preoccupied with body image. B.The client is preoccupied with food consumption. C.The client has feelings of powerlessness. D.The client is of normal body weight.
D.The client is of normal body weight.
A nurse who works in a psychiatry unit finds that young clients with schizophrenia have worse prognoses when compared with clients who are diagnosed later in life. Which reasons should lead the nurse to make this observation? Select all that apply. A.They have less sense of personal identity. B.They are less adherent to the treatment schedule. C.They are not able to accurately communicate their issues and concerns. D.They are inherently more susceptible to a poor prognosis. E.They are less likely to have experiences of independent living.
D.They are inherently more susceptible to a poor prognosis. E.They are less likely to have experiences of independent living. A.They have less sense of personal identity.
Which addresses the psychological domain of biopsychosocial interventions for a client with borderline personality disorder? A.Environmental management B.Prevention of self-harm C.Communication skills D.Withdrawing attention as much as possible
D.Withdrawing attention as much as possible