Mental Health

How would you describe your gender?

A new nurse is caring for an adolescent transgender client. What question would be appropriate when assessing the client's gender identity? Explanation Transgender clients may fear judgment or embarrassment and withhold information, avoid seeking treatment, or refuse care as a result. This is often related to past experiences of discrimination or stigma when receiving health care. Therefore, it is important to use therapeutic communication and avoid stereotypes to establish trust. Transgender clients may identify as male or female or as neither or both genders. It is important for the nurse to determine clients' gender identity by asking open-ended questions that allow clients to explain their identities in their own words (Option 2). (Option 1) The client may not identify as simply male or female. Asking closed-ended questions (eg, whether the client prefers "he" or "she") does not allow for client elaboration. (Option 3) Because the client does not identify with the gender designated at birth, referring to a transgender client's "original gender" may cause distress and discomfort. The nurse should instead ask what sex the client was assigned on the original birth certificate. (Option 4) Asking "What is your preferred name?" is not open-ended and does not thoroughly assess gender identity. However, the client's preferred and legal names may be different. The nurse should use the client's preferred name to show respect and to develop a therapeutic relationship. Educational objective:Transgender clients may identify as male or female or as neither or both genders. The nurse should use open-ended questions that allow clients to explain their identities in their own words.

Explain all activities of care clearly and calmly while facing the client

A nurse is caring for a client who has tested positive for amphetamines and is experiencing paranoia. The client has a history of physical violence. Which intervention should the nurse implement at this time to prevent the client from becoming violent? Explanation Violence in the health care setting poses a safety risk to clients, staff, and visitors. It also decreases the quality of care that a violent client receives due to avoidant and fearful behaviors by staff. Risk factors for violence include altered level of consciousness, substance abuse, emotional stress, and behavioral/psychiatric disorders. Nursing interventions that help prevent violence include using clear, thorough communication (Option 2); encouraging active participation in care; promoting a low-stimulation environment; and providing comfort through pharmacological and nonpharmacological methods. The nurse should demonstrate undivided attention to the client (eg, facing the client, unhurried body language, calm tone). (Option 1) Chemical (eg, lorazepam) and physical restraints should be used only as last resorts to keep clients and others safe. It is not appropriate to use restraints to prevent escalation to violence. (Option 3) Placing the client near the nurses' station may increase anxiety due to the noise and activity in that area. The client should be closely monitored, but this is not an effective intervention for preventing violence. (Option 4) The presence of security personnel does not prevent violence and may cause increased client anxiety. The nurse should consider other interventions (eg, effective communication) to prevent violence. Educational objective:Violence is a safety concern for all in the health care setting. Nurses must identify those at risk for violent behavior and use clear, thorough communication to prevent violence. The nurse should provide undivided attention to the client while explaining all activities of care in a calm tone.

80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis

A nurse performs the initial assessments for 4 assigned clients. The nurse identifies which client as being at greatest risk for the development of delirium? Explanation Major predisposing factors for the development of delirium in hospitalized clients include: Advanced age Underlying neurodegenerative disease (stroke, dementia) Polypharmacy Coexisting medical conditions (eg, infection) Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia) Metabolic and electrolyte disturbances Impaired mobility - early ambulation prevents delirium Surgery (postoperative setting) Untreated pain and inadequate analgesia Client 4 has 4 predisposing risk factors: advanced age, acidosis and hypoxemia associated with chronic respiratory failure, and sepsis. This client is at greatest risk for developing delirium. (Option 1) Although gastroenteritis with possible dehydration and electrolyte imbalances predisposes to delirium, this client is not at greatest risk. (Option 2) Although surgery, especially that requiring cardiac bypass, predisposes to delirium, this client is not at greatest risk. Early ambulation and adequate pain control prevent the development of delirium in the postoperative setting. (Option 3) Although coexisting medical conditions, such as diabetes mellitus and impaired mobility, predispose to delirium, this client is not at greatest risk. Educational objective:Risk factors for hospital-induced delirium include advanced age, underlying neurodegenerative disease, infections, medical illness, surgery, impaired mobility, and inadequate pain control.

4."This is a difficult time. Tell me about how you have been coping." 5."What are your thoughts about attending a grief support group?"

A recently widowed client becomes tearful at a routine clinic visit and states, "I just can't get over my spouse's death." Which of the following responses by the nurse are appropriate? Select all that apply. Explanation The practices, needs, and experiences of grief vary greatly among individuals. Nurses caring for grieving clients must skillfully use therapeutic communication techniques to strengthen the nurse-client relationship and support clients in exploring emotions and experiences. Reflection (eg, acknowledging client statements) and using open-ended questions or statements assist the client in exploring emotions and allow for expression of needs (Option 4). Nurses may also suggest strategies and share resources (eg, support group) to facilitate the client's grieving process (Option 5). (Option 1) Presuming to understand another individual's grief based on personal experience is not a therapeutic communication technique as it diminishes the experiences and emotions of the client. (Option 2) Clients expressing strong emotions may need time to collect themselves before continuing a discussion. However, leaving the room when a client's emotions are heightened may imply that the client's expression is inappropriate or unacceptable. The nurse should remain with the client and may use therapeutic silence or touch to show support. (Option 3) Automatic or cliché responses (eg, it takes time to deal with losses) are nontherapeutic as they limit discussion and expression of the client's experience and emotion. Educational objective: Nurses should use therapeutic communication techniques (eg, reflecting, asking open-ended questions, suggesting strategies or resources) to support clients' psychosocial needs and build the nurse-client relationship. Minimization, automatic responses, and leaving clients who are sharing strong emotions are nontherapeutic actions.

Client with schizophrenia hearing voices advising to harm a neighbor

The clinic nurse reviews telephone messages left by 4 clients. Which client is the priority to call back first? Explanation Auditory hallucinations are the most common form of hallucination, noted by falsely perceived sounds, most often in the form of voices. Command hallucinations are a specific type of auditory hallucination, during which voices instruct the client to perform specific actions, often demanding harm to the client or others. Clients who are alone and experiencing command hallucinations that are homicidal or suicidal in nature require immediate intervention to ensure the safety of themselves and others (Option 2). (Option 1) A client experiencing addiction cravings needs assistance but is not a priority over a client with command hallucinations demanding harm to others. (Option 3) Parents of clients with conduct disorder need guidance and training to appropriately respond to problem behavior; however, this is not an immediate safety risk. (Option 4) A spouse calling about a suicidal client is not the first priority; the client is not alone, and the spouse can call others for help (eg, police, suicide hotline) if necessary while awaiting the nurse's return call. This should be the second returned call. Educational objective:A client who is alone with command hallucinations that are homicidal or suicidal in nature requires immediate intervention to prevent harm. Clients who are homicidal or suicidal but are with another person should be addressed after those who are alone.

"You sound very discouraged and frightened."

The health care provider has just informed a client who has diabetes and chronic kidney disease of the need to start dialysis. The client tearfully says to the nurse, "I don't know what I'm going to do; everything was so overwhelming before, and now there is this." How should the nurse respond? Explanation Clients may feel overwhelmed when managing chronic illnesses. The nurse should assist them in processing difficult news or events through discussion of thoughts and feelings, which also fosters rapport. Reflecting, or referring the statement back to the client, is a therapeutic communication technique that promotes open dialogue and encourages the client to recognize feelings (Option 3). Acknowledging feelings is an important step in successfully navigating difficult circumstances. (Option 1) Encouraging the client to cry if needed conveys concern but does not encourage further discussion of feelings. (Option 2) Giving false reassurance is an example of a nontherapeutic communication technique that may seem supportive; however, it inappropriately offers hope for an outcome that the nurse cannot guarantee. False reassurance also invalidates and hinders discussion of the client's feelings. (Option 4) Making cliché statements or automatic responses (eg, "you have a lot to live for") or shifting the focus to others' feelings (eg, "think about your family") invalidates the client's feelings and impedes open communication. Educational objective: Nurses should assist clients in processing difficult news or events through discussion of thoughts and feelings. Reflecting is an appropriate technique that promotes open communication and encourages the client to recognize feelings.

4."What happened is not your fault. You are not to blame." 5."You did the right thing by telling me. You are not in trouble."

The nurse assesses a pediatric client and finds bruises in various stages of healing on the back and legs. When questioned about the bruises the child begins to cry and states, "Somebody did things to me." Which of the following communications by the nurse is appropriate? Select all that apply. Explanation When speaking with a child about abuse, the nurse should be direct and honest. The nurse should allow the child to disclose the abuse at a comfortable pace, rather than probe for additional information. The nurse should use open-ended questions and avoid leading questions and statements. Guidelines for the interview: Speak with the child in private Be honest about reporting requirements Use language appropriate to the child's age Avoid making assumptions or communicating anger, shock, or disapproval Reassure the child about not being at fault or in trouble (Options 4 and 5) (Option 1) The nurse should not make assumptions about who abused the child. This could lead to bias or false accusations and/or cause the child to fear revealing the identity of the abuser. (Option 2) "Tell me about what happened" is a correct, open-ended question; however, the nurse is required to report abuse and should communicate this requirement to the child. (Option 3) The nurse should avoid making derogatory statements about the abuser, as this can cause the child feelings of embarrassment or fear and end the conversation. Educational objective:When interviewing a child about abuse, the nurse should affirm that the child is not at fault or in trouble and avoid making assumptions or communicating anger, shock, or disapproval. The nurse should be direct and honest about the requirement to report abuse.

Assess the client for thoughts of self-harm Collaborate with the health care team to develop a safety plan Document the client's injuries on a body map

The nurse in the emergency department is caring for a client at 10 weeks gestation who reports being abused by her spouse but is not ready to leave the relationship. Which of the following interventions are appropriate? Select all that apply. Explanation Intimate partner violence (IPV) is physically, emotionally, verbally, sexually, or economically abusive behavior inflicted by one partner against the other in an intimate relationship to maintain power and control. During pregnancy, added emotional and financial stress may trigger or escalate abuse. The abuse can endanger the health and safety of both mother and fetus. The nurse should work closely with survivors of IPV to ensure their safety in the event of escalating violence. Appropriate interventions include the following: Assess the client for thoughts of self-harm because the client may view suicide as the only way out of the relationship (Option 2). Collaborate with the health care team to develop a safety plan, which facilitates rapid escape from escalating violence. Components of a safety plan include a secure location to reside and an emergency kit with essential items (Option 3). Follow facility guidelines for reporting, documenting, gathering evidence, and/or photographing injuries. Thorough documentation of details of the injury on a body map will be needed to facilitate any legal proceedings (Option 4). (Option 1) Identifying which client behaviors trigger the abuse places blame on the client rather than the abuser. The client is not responsible for the abuse. (Option 5) Unless the client expresses desire to leave the relationship, advising the client to live with a relative is not appropriate. Educational objective:Intimate partner violence (IPV) is abusive behavior inflicted by one partner against the other. Appropriate interventions for survivors of IPV include developing a safety plan, assessing for self-harm, and obtaining and documenting evidence of injuries.

1. "Drinking led to my divorce and the loss of my children." 4. "My focus is now on fitness training and going back to college." 5. "When cravings occur, I call my Alcoholics Anonymous sponsor."

The nurse in the outpatient treatment facility evaluates the plan of care for a client with alcohol use disorder. Which of the following client statements indicate positive progress toward recovery? Select all that apply. Evaluation Alcohol use disorder, or alcoholism, occurs when alcohol is consumed in excess over time until dependence develops, causing withdrawal to occur when alcohol is not consumed. Alcohol consumption can become the client's sole focus, which negatively impacts the social, familial, and occupational aspects of the client's life. After the detoxification period, the plan of care includes a goal-setting process to progress the client toward total abstinence from alcohol. Goals for client recovery include: Expressing accountability for previous behavior, including how abusing alcohol has impacted personal life (Option 1) Using insight to face reality and overcome rationalization and projection Using coping skills (eg, support groups, relaxation techniques) to improve reactions to stressful situations (Option 5) Setting goals for personal growth and self-worth development and using nonchemical alternatives (eg, fitness training) for stress relief (Option 4) Maintaining abstinence from alcohol consumption (Option 2) This statement represents denial, a common maladaptive defense mechanism in which substance misuse or addiction is minimized and/or clients deny having a problem with substance use. (Option 3) This statement represents rationalization, a common maladaptive defense mechanism in which the client makes excuses (eg, divorce) to justify substance use. Educational objective:Clients recovering from alcohol use disorder should demonstrate accountability for past behavior and identify the consequences, use insight to face reality, and use coping skills and nonchemical alternatives. The client should also be encouraged to set goals for personal growth.

Cheeseburger, apple, vanilla milkshake

The nurse is caring for a client newly admitted with an acute manic episode of bipolar disorder. The nurse identifies which dinner selection as the most appropriate to promote client nutrition? Explanation Bipolar disorder is a psychiatric condition characterized by cycling periods of depression and mania. Clients with acute mania often display elevated mood, increased and excessive activity levels, and altered decision-making that can result in high-risk behavior (eg, hypersexuality, excessive spending). Clients with mania are also easily distractible, leading to neglect of personal needs (eg, hydration, nutrition, sleep, hygiene) and the need for medical intervention. When managing the nutritional needs of clients with mania, the nurse should frequently offer energy- and protein-dense foods that are easily carried and consumed (eg, sandwiches, shakes, hamburgers, pizza slices, burritos, fruit juices, granola bars). These "on-the-go" foods promote nutritional intake in clients who are unable to sit down and complete a traditional meal (Option 2). (Option 1) Sweet potatoes and kale are low in energy and protein and difficult to eat on the go. (Option 3) Spaghetti with meatballs and fruit salad are difficult to eat on the go. (Option 4) Vegetable soups and salads are often low in protein and energy and difficult to eat on the go. Caffeinated drinks (eg, soda, tea, coffee) should be avoided as they may increase mania and activity. Educational objective:Clients with acute mania often have elevated activity levels that increase their risk for malnutrition and dehydration. Nurses should provide easily carried and consumed foods high in energy and protein (eg, burgers, sandwiches, shakes) to promote adequate nutritional intake.

"Your son will have to remain here for observation until we know more."

The nurse is caring for a client who entered the psychiatric emergency department in a state of acute psychosis after ingesting illicit substances. The parents ask the nurse if the client will develop schizophrenia. What is the most appropriate response by the nurse? Explanation It is important to distinguish clinically between the very similar presentations of intoxication, delirium secondary to a medical condition, dementia, and psychiatric disorders involving distorted perceptions of reality in order to begin the appropriate treatment. Some illicit substances (eg, marijuana, LSD, PCP) have been reported to cause episodes of severe, acute psychosis. Some clients will never experience another episode of psychosis. However, in rare cases, illicit substances may trigger a genetic predisposition to development of a mental illness. There is no way to establish the long-term prognosis. (Option 1) The long-term prognosis after an episode of psychosis is impossible to predict with any accuracy. It is tempting to offer comfort to a client's family in a time of crisis, but the nurse should never make promises. (Option 2) Most cases of drug-induced psychosis are transient. (Option 4) After substance abuse has been verified, client education regarding drug abuse and therapy or counseling are indicated. However, it is extremely unprofessional to judge clients for their behavior and lifestyle choices. Educational objective:Clients demonstrating altered mental status should be assessed for intoxication and medical causes of delirium (electrolyte/glucose imbalances, pneumonia, sepsis, malnutrition) prior to involving a mental health care professional.

1. Conduct a suicide risk assessment 2.Perform mouth checks during medication administration 3.Place the client on one-to-one observation 5.Remove the client's necklace and shoelaces

The nurse is caring for a client who is experiencing active suicidal ideation. Which of the following interventions are appropriate? Select all that apply. Explanation When caring for a client experiencing suicidal ideation, it is essential to develop a therapeutic alliance by communicating empathy and building trust. Hospitalization to maintain safety is indicated for clients with active suicidal ideation, a specific suicide plan, and intent to act. Interventions to promote safety and reduce the risk of suicidal actions include: Conducting a suicide risk assessment, which includes directly asking the client about details of suicidal ideation (eg, method, plan, intent) (Option 1) Performing mouth checks to ensure that the client has swallowed pills because clients can hoard medication and attempt to overdose later (Option 2) Assigning staff to continuously observe the client (ie, one-to-one observation) (Option 3) Ensuring that the client does not have access to items that could be used for self-harm (eg, necklace, shoelaces, extra bedsheets) (Option 5) Placing the client in the room closest to the nurses' station to allow easier access to the client (Option 4) Discharging a client who has active suicidal ideation is not appropriate because of the risk for self-harm. An intensive outpatient program will likely be indicated once the client's condition is stable (eg, absence of suicidal ideation). Educational objective:When caring for a client with active suicidal ideation, the nurse should conduct a suicide risk assessment, perform mouth checks during medication administration, place the client on one-to-one observation, and remove access to items that could be used for self-harm.

"I found several empty boxes of laxatives in my child's wastebasket."

The nurse is conducting a seminar for parents of adolescents about health issues common to this age group. Which parent's statement indicates that the adolescent may have bulimia nervosa? Explanation Bulimia nervosa (BN) is an eating disorder characterized by episodes of uncontrollable binge-eating (consuming very large amounts of food, often in secret) followed by inappropriate compensatory behaviors to prevent weight gain. Compensatory behaviors may include laxative or diuretic use, self-induced vomiting, or excessive exercise 1-2 hours after binging (Option 1). Other signs of BN may include: Physical changes related to self-induced vomiting (eg, scars or calluses on the hand, enlarged parotid glands, erosion of tooth enamel, dental caries) Preoccupation with body image, weight, food, and dieting (Options 2 and 3) Losing a significant amount of weight and hiding the weight loss (eg, wearing oversized, bulky clothing) are characteristics of clients with anorexia nervosa. (Option 4) A client with BN would likely increase the amount of time spent exercising, not stop exercising. Educational objective:Bulimia nervosa is an eating disorder characterized by episodes of binge-eating followed by actions to prevent weight gain (eg, laxative overuse, self-induced vomiting, excessive exercise).

Give the child a written schedule of daily activities

The nurse is planning care for an 11-year-old admitted for surgical treatment of a fractured femur. The child also has attention-deficit hyperactivity disorder, predominantly inattentive type. What is the priority nursing action? Explanation Children with attention-deficit hyperactivity disorder (ADHD), predominantly inattentive type, have trouble holding attention on tasks or play activities, experience difficulty organizing tasks and activities, and are easily distracted/side-tracked. They cannot give close attention to detail and dislike and/or avoid tasks that require mental effort over a long period. The key nursing intervention to help the child with ADHD adjust to hospitalization is providing a calm, structured, organized, and consistent environment. A written chart or list of daily activities will help remind the child of what to expect and what will happen at any given time. A structured environment helps these children organize their thoughts and activities. (Option 1) It is important for the child to keep up with school work to the fullest extent possible so the child does not fall behind. Catching up will be more difficult for a child with ADHD than for a child without the diagnosis. A structured environment can help the child plan time for school work. (Option 3) It is important that children with ADHD have visitors as they will likely have impaired social skills and may feel socially isolated. However, the number of visitors may need to be limited to avoid an overly distracting environment. (Option 4) Verbal explanations of what to expect during hospitalization can be provided in a clear, concise manner that allows the child to ask questions. However, because this child will be easily distracted, will not seem to listen when spoken to directly, and is often forgetful, verbal instructions may not be the most effective communication approach. Educational objective:The most important nursing intervention in caring for a child with ADHD is providing a structured, consistent, and organized environment. A written schedule of activities will remind the child what to expect at any given time.

Diaphoresis Hallucinations Tachycardia

The nurse is preparing discharge instructions for a client with a history of alcohol abuse on the third day after an emergency appendectomy. The nurse suspects delirium tremens based on which assessment data? Select all that apply. Severe alcohol withdrawal symptoms such as shaking, confusion, and hallucinations. Explanation One of every 6 clients undergoing an emergency surgical procedure will show some signs of alcohol withdrawal during the hospital stay. Screening for heavy use of drugs and alcohol should occur at several points during hospitalization to avoid complications of withdrawal. Delirium tremens and other withdrawal symptoms can be prevented with benzodiazepine administration during hospitalization. The stages of alcohol withdrawal do not always occur as a progressive sequence. (Option 1) Decreased respiratory rate is not a sign of alcohol withdrawal. It is more commonly seen in alcohol or opiate overdose. (Option 4) Clients experiencing alcohol withdrawal symptoms will be agitated and have tremors and hyperreflexia. Educational objective:Alcohol dependency is frequently missed during the admission process. Clients should always be screened for heavy use of alcohol or benzodiazepines as withdrawal is potentially life-threatening and avoidable. Signs and symptoms of delirium tremens include agitation, fever, tachycardia, hypertension, and diaphoresis.

Encourage the client to talk about the trauma

The nurse is providing care to a client experiencing post traumatic stress disorder following a terrorist attack at the client's place of worship. What is the priority nursing action? Explanation The first step toward resolution of posttraumatic stress disorder (PTSD) is the client's readiness (ability and willingness) to discuss the details of the traumatic event without experiencing high levels of anxiety. The nurse must assess clients with PTSD for their readiness to talk about the experience and encourage them to discuss the trauma at their own pace. The nurse should also use active listening as a therapeutic approach to build trust and allow clients to vent. This will assist in decreasing their feelings of isolation. The nurse can also guide the client in identifying event details that are most troubling and trigger a sense of loss of control. The effectiveness of the client's coping mechanisms can be identified, and alternate strategies to replace maladaptive ones can be explored. (Option 1) It is important to acknowledge any feelings that the client may have about the trauma; the priority nursing action is to encourage the client to talk about the event. (Option 2) Assessing the client's support system is an appropriate nursing intervention; however, it is not the priority. (Option 4) Sleep aids are used for clients with PTSD and insomnia; however, this is only a temporary solution to one aspect of PTSD clinical presentation. Educational objective:The nurse should encourage clients with posttraumatic stress disorder to talk about the experience at their own pace, listen actively to build trust, and allow clients to vent. This will assist in decreasing their feelings of isolation.

1.Client abruptly quit sports despite receiving previous athletic awards and trophies 2.Client has had school disciplinary issues due to absenteeism and angry outbursts 3.Client has unintentionally lost approximately 8 lb (3.6 kg) over the past 3 weeks 4.Client is often found sleeping during class or after-school activities

The nurse is reviewing the records of an adolescent client. Which of the following findings suggest that the client may need to be screened for depression? Select all that apply. Explanation Adolescents are at increased risk for depression as they begin to identify their role in adult life and develop new interpersonal relationships. Depressive symptoms in children manifest differently compared to adults, and symptoms are often subtle. The nurse should be able to distinguish childhood depression versus normal childhood behavior and follow-up immediately because untreated depression can lead to thoughts of self-harm. Depressive symptoms include: Social withdrawal from loved ones and loss of interest in previously enjoyed activity (eg, abruptly quitting sports) (Option 1) Irritable mood, angry outbursts, aggressive or delinquent behavior (eg, vandalism, absenteeism) (Option 2) Appetite changes resulting in fluctuations in weight (eg, weight loss, weight gain) (Option 3) Sleep disturbances (eg, insomnia, hypersomnia) (Option 4) Vague somatic symptoms (eg, headache, stomachache) without a cause Treatment consists of a multimodal approach, including psychotherapy (eg, cognitive-behavioral therapy) and selective serotonin reuptake inhibitors (SSRIs) (eg, sertraline). (Option 5) Adolescents begin to become more aware of body image and may express concern regarding their appearance. It is normal for clients in this age group to experience insecurity about their appearance (eg, acne, body hair). These insecurities do not correlate with the onset of a depressive disorder. Educational objective:Adolescents are at increased risk for depression as they begin to identify their role in adult life and develop new interpersonal relationships. Depressive symptoms in children include social withdrawal, irritable mood, aggressive or delinquent behavior, appetite changes, sleep disturbances, and vague somatic symptoms (eg, headache, stomachache) without a cause.

That song is a message sent to me in secret code.

The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom? Explanation Delusions are one of the positive symptoms of schizophrenia. Delusions are false beliefs that have no basis in reality and are unrelated to a client's culture or intelligence. When presented with proof that the delusion is irrational or untrue, the client continues to believe it is real. Clients experiencing delusions of reference will believe that songs, newspaper articles, and other events are personal and significant to them. Other examples of delusions are below: Grandeur - "I need to get to Washington for my meeting with the president." Control - "Don't drink the tap water. That's how the government controls us." Nihilistic - "It doesn't matter if I take my medicine. I'm already dead." Somatic - "The doctor said I'm fine, but I really have lung cancer." (Option 1) This client statement is an example of a tactile hallucination, which gives the client the sensation of being touched. (Option 2) This client statement is an example of an auditory hallucination, specifically a command hallucination. Clients experiencing auditory hallucinations hear sounds and voices others do not. (Option 4) This client statement is an example of a persecutory (paranoid) delusion. Clients with such delusions believe that they are being threatened or treated unfairly in some way. Educational objective:Delusions are a positive symptom of schizophrenia. Delusions of reference cause clients to feel as if songs, newspaper articles, and other events are personal to them.

Displacement

The nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family meeting and immediately begins to verbally abuse a roommate? Explanation Displacement, one of many ego defense mechanisms, occurs when a person shifts uncomfortable feelings or impulses about one situation or person to a substitute situation or person deemed acceptable to receive these uncomfortable feelings or impulses. (Option 1) Compensation involves experiencing a perceived deficit in one area and making up for it by overachieving in another. An example is someone not doing well academically who focuses on doing well in sports. (Option 3) Projection involves feeling uncomfortable with an impulse or feeling and easing the anxiety by assigning it to another person. An example is a husband with thoughts of infidelity who then accuses his wife of being unfaithful. (Option 4) Reaction formation involves transforming an unacceptable feeling or impulse into its opposite. An example is a client with cancer who fears dying but behaves in an overly optimistic and fearless manner about his treatment and prognosis. Educational objective:Displacement is an ego defense mechanism that involves transferring uncomfortable feelings, emotions, or impulses about one person or situation to a substitute person or situation.

Increases caloric intake to gain weight

The nurse plans care for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. Which client outcome will the nurse prioritize? Explanation Anorexia nervosa is an eating disorder characterized by distorted body image, profound fear of weight gain, a strong desire to be thin, and being unwilling to maintain a healthy body weight. The client engages in behaviors to lose weight, including not eating, purging, extreme exercise, and use of laxatives and diet pills. Psychosocial issues leading to anorexia are the focus of ongoing therapy, usually on an outpatient basis. However, certain criteria require hospitalization and include body weight below 75% of ideal, suicidal behavior, or medical conditions resulting from starvation. The priority focuses during inpatient care are the short-term outcomes of restoring caloric intake, promoting gradual weight gain, and treating medical conditions caused by starvation. (Options 1, 2, and 4) Acknowledging poor interpersonal skills, identifying new coping mechanisms, and verbalizing sources of conflict and anger are important but will not be the focus during hospitalization. These long-term outcomes will be addressed during ongoing therapy. Educational objective:Treatment for a client requiring hospitalization for anorexia nervosa should focus on the short-term outcomes of increasing caloric intake, promoting gradual weight gain, and addressing medical conditions caused by starvation.

"I am currently unemployed and looking for a job." "I have multiple firearms at home stored in a safe." "It has been about a year since I last overdosed." "Sometimes I experience feelings of hopeless."

The triage nurse is assessing a client's risk for suicide after the client reports having thoughts of self-injury yesterday. Which of the following statements by the client should the nurse recognize as risk factors for suicide? Select all that apply. Explanation Suicidal ideation is a preoccupation with thoughts of self-harm and death. Active suicidal ideation is recognized as the constant consideration of suicide that involves the formulation of a suicide plan. Ideation and suicide risk factors may fluctuate over time and may be time limited. The nursing priority when caring for a client with suicidal ideation is ensuring client safety. The following risk factors place the client at increased risk for death by suicide: Significant life stressors (eg, unemployment, difficulty finding a new job) (Option 1) Access to devices used for self-harm (eg, firearms) (Option 3) Substance abuse and previous history of overdose (Option 4) Feelings of hopelessness (ie, doubts that anything will improve) (Option 6) After performing a suicide risk assessment, the triage nurse should recognize that this client is at increased risk and should next evaluate if the client has a plan for self-harm. The risk increases if the client has a specific time, place, and lethal method planned. The nurse should communicate findings to the health care provider immediately to initiate a collaborative safety plan specific to the client. (Options 2 and 5) Protective factors are supportive mechanisms that increase client resiliency and decrease the likelihood of death by suicide (eg, family/social support, pregnancy, participation in religious activities). Educational objective:Suicidal ideation is a preoccupation with thoughts of self-harm and death. The nurse should understand risk factors of suicide, including feelings of hopelessness, substance abuse, access to methods of self-harm, and significant life stressors.

1. Amenorrhea 2. Fluid and electrolyte imbalances 4. Presence of lanugo 6. Weight loss of 25% below normal weight

Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply. Anorexia nervosa is an eating disorder common among adolescents and young adults. Clinical manifestations of anorexia nervosa include: Fear of weight gain - clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands and erosion of tooth enamel. Fluid and electrolyte imbalance - excessive vomiting can cause hypokalemia and metabolic alkalosis Amenorrhea - clients are often amenorrheic due to decreased body fat (low estrogen) Decreased metabolic rate - severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance Lanugo (fine terminal hair) can be seen in extreme cases Manifestations of anorexia nervosa will resolve after the weight loss is corrected, although the recovery process can take several months. (Option 3) Anorexia nervosa manifests as cold intolerance. (Option 5) Anorexia nervosa manifests as lengthy and vigorous exercise. Educational objective:The clinical manifestations of anorexia nervosa include extreme weight loss, amenorrhea, bradycardia, cold intolerance, dry skin, and lanugo. Life-threatening complications, such as cardiac arrhythmias associated with hypokalemia, may develop.

"My mother could not drive me here today, so I took the bus."

Which statement by a client with a diagnosis of dependent personality disorder would the nurse recognize as progress toward a positive therapeutic outcome? Explanation Individuals with dependent personality disorder have a persistent and extreme need to be taken care of that manifests as submissive and clinging behaviors and fear of separation. Additional characteristics of dependent personality disorder may include: Difficulty in making day-to-day decisions An excessive need for advice, reassurance, and nurturance from others Lack of self-confidence - afraid to do things on one's own Afraid of confrontation or expressing disagreement with others Feelings of helplessness and anxiety when alone; fear of being unable to take care of oneself A client making a decision about and carrying out a daily activity on his/her own would be indicative of progress toward a therapeutic outcome. (Option 1) Clients with dependent personality disorder will often express appreciation or make flattering comments to the nurse/therapist to gain approval. (Option 2) Clients with dependent personality disorder lack confidence in their own abilities; this client is expressing self-doubt and is not showing evidence of improvement. (Option 4) The need to stay with someone while the client's parents are away is not evidence of progress toward a therapeutic outcome; the client cannot tolerate being alone. Educational objective:Clients with dependent personality disorder have an extreme need to be taken care of by another person, cannot make decisions on their own, and have intense fear of separation and being left alone. The ability to make a decision and act on one's own would indicate progress toward a therapeutic outcome.

Connect-the-dots puzzle book

A 12-year-old with moderate intellectual disability and an intelligent quotient of 45 is hospitalized. What will the nurse recommend as the best recreational activity for this child? Explanation Activities for children with intellectual disabilities should be based on the child's developmental age with consideration given to size, coordination, physical fitness, maturity, likes and dislikes, and health status. A child with moderate intellectual disability: Has academic skills at about the 2nd grade level and may be able to work in a sheltered workshop Performs self-care activities with some supervision Participates in simple activities May have limited speech capabilities Appropriate play activities for this child include simple puzzles, coloring books and crayons, modeling clay, watching cartoons or favorite movies, sticker books, playing with a large ball (eg, inflatable beach ball), simple card and board games, and being read to aloud. (Option 1) Most children would like having their favorite stuffed animal while hospitalized, but it is not the best choice for this child. The toy may be comforting but does not offer the child the opportunity to engage in active play. (Option 3) A 300-piece jigsaw puzzle would be too challenging and frustrating for a child with moderate intellectual disability. (Option 4) Keeping a journal about the hospital stay is a more appropriate activity for a child with a higher level of intellectual development (ie, one who has achieved high school level academic skills). Educational objective:Activities for children with intellectual disabilities should be based on developmental age with consideration given to the child's size, coordination, physical fitness, maturity, likes and dislikes, and health status.

Insist on school attendance immediately, starting with a few hours a day

A child with a high level of school absenteeism has been determined to have school phobia. The school nurse should counsel the child's parent/caregiver to take which action? Explanation School phobia (also known as school refusal or school avoidance) is a childhood anxiety disorder in which the child experiences an irrational and persistent fear of going to school. Having the child return to school immediately is the best approach for resolving school phobia and is associated with a faster recovery. If necessary, gradual exposure to the school environment can be implemented; the child can attend school for a few hours and then gradually increase the time to a full day. A gradual approach may decrease the child's sensitization to the classroom. If the child is allowed to remain out of school, the problem will only worsen, with potential deterioration of academic performance and social relationships. (Option 1) Allowing the child to stay home will only reinforce the acting-out behaviors associated with refusal to attend school. The parent/caregiver needs to support the child and talk about the cause of the anxiety, but the child needs to go to school. (Option 2) Having the parent/caregiver stay in the classroom with the child is not a permanent solution to relieving the child's anxiety and is not recommended. (Option 4) Determining the cause of the school phobia is important in helping to alleviate the child's symptoms and in coping with the return to school. However, returning the child to the classroom immediately is the most important action. Educational objective:A child with school phobia needs to return to the classroom immediately. Insisting on school attendance, along with other supportive interventions, will help the child make a faster adjustment.

Depressed mood or loss of interest or pleasure

A client has been admitted to the acute inpatient psychiatric unit with a diagnosis of major depressive disorder (unipolar depression). The nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which of the 2 key clinical findings daily for at least 2 weeks? Evaluation Major depressive disorder (also known as unipolar depression) is a subtype of depressive disorder, classified by specific symptoms that interfere with the ability to perform activities of daily living, work, sleep, and enjoy activities that are usually pleasurable to the client. For the diagnosis to be made, 5 or more of the following symptoms must be present almost every day for at least 2 weeks, and 1 of the symptoms must be depressed mood or loss of interest or pleasure. (Option 1) Daily sleep disturbance or significant weight loss is a symptom of depressive disorders; these are not key clinical features necessary for diagnosis. (Option 2) Decreased ability to think or low energy is a symptom of depressive disorders; these are not key clinical features necessary for diagnosis. (Option 4) Thoughts of worthlessness or recurrent thoughts of death are symptoms of depressive disorders; these are not key clinical features necessary for diagnosis. Educational objective:The 2 key clinical features of major depressive disorder (unipolar depression) are depressed mood and loss of interest or pleasure. One of these symptoms must be present daily for at least 2 weeks for the diagnosis of major depressive disorder to be made.

"This has been very overwhelming for you. What are you feeling right now?"

A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead. I can't believe this is happening." What is the best response by the nurse? Explanation This client's spouse has experienced a traumatic or crisis event (also referred to as "a critical incident"). When faced with a traumatic situation, clients are often overwhelmed and respond with a wide range of emotions and thoughts, including shock, denial, anger, helplessness, numbness, disbelief, and confusion. Clients may also experience physical symptoms, such as hyperventilation, abdominal pain, and dizziness. Priority nursing actions need to be directed at the here and now, providing therapeutic interventions aimed at alleviating the immediate emotional impact of this disruptive crisis event. Acknowledging the severity of the event validates and normalizes the spouse's reaction. Assisting the spouse in identifying feelings and giving the spouse opportunity to ventilate will help reduce immediate emotional stress. (Option 1) Assessing this family's support system is important. However, it is not the priority action at this time. (Option 2) This statement does not address what this client's spouse is experiencing at the moment. At a later time, the nurse can explore the client's history and any events that may have lead to this situation. (Option 4) This response does not address the spouse's concerns. Also, the wording is judgmental and non therapeutic. Educational objective: Initial reactions to a crisis event may include shock, disbelief, denial, helplessness, and confusion. Nursing actions are directed at providing support to the client. Acknowledging the impact of the event and encouraging the client to ventilate are therapeutic interventions.

2.Focus on reality and verbally reinforce it 3.Focus on the client's feelings secondary to the delusions

A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions. Which nursing interventions should the nurse include in the client's plan of care with regard to the delusional thinking? Select all that apply. Explanation Clients with persecutory delusions (paranoid delusions) believe that they are being persecuted or harmed (eg, spied on, cheated, followed, poisoned). Focusing on the client's feelings secondary to the delusion is an example of empathy, one of the most important parts of the therapeutic nurse-client relationship. When nurses attempt to understand clients' feelings and their meaning, clients realize that someone is trying to understand them and the nurse-client relationship grows (Option 3). Focusing on reality and verbally reinforcing it will decrease the time that the client spends thinking about the delusions (Option 2). For example, the nurse may focus on the client's feelings by stating, "I understand that it is frightening to know that someone is trying to poison you." Reality orientation may also be helpful by telling the client, "What you are thinking is part of your disease and not real." (Option 1) Attempting to explore the meaning behind a delusion will encourage the client to focus/think more on this delusion. (Option 4) Confronting the client about the delusion is not therapeutic because arguing will not eradicate the delusion. It also hinders the development of a trusting nurse-client relationship. (Option 5) Clients believe that their delusions are real despite proof otherwise. Presenting logical explanations to discredit the delusions will not help. Educational objective:When communicating with a delusional client, the nurse must focus on the client's feelings and reinforce reality rather than argue or present evidence that the delusion is false or irrational.

Provide continuous one-to-one observation with the client

A client on a medical unit recently received a diagnosis of end-stage renal disease and was told of the need to go on dialysis. This morning the client was found in the bathroom trying to commit suicide by hanging using hospital gown ties. The client was stabilized and transferred to the psychiatric unit. Which of the following is the highest priority nursing action for this client? Explanation This client has made a suicide attempt and is at high risk for additional suicidal behavior. Therefore, the client's priority need is for safety. The best nursing action is to provide one-on-one contact with the client to ensure constant observation and that the client does not engage in self-harm. The presence of the nurse will also convey a sense of acceptance, concern, and caring and provide an opportunity for the client to express feelings about the current situation. Additional nursing interventions for the client at high risk for suicide include the following: Removing sharp and other potentially harmful objects (eg, belts, metal eating utensils, ties, glass items) from the client's environment Making sure the client swallows medications Supervising the client during meals Placing the client in a semiprivate room near the nurses' station (to reduce social isolation and allow easier access to the client) Making rounds at irregular intervals for the client who does not need constant observation, as well as at shift changes and when staff is unusually busy Encouraging the client to express feelings, especially anger Having an open and honest conversation with the client about changing suicide risk (Option 1) This is an appropriate nursing action but not the highest priority action. (Option 2) This is an appropriate nursing action but not the priority action. (Option 3) A client at risk for suicide should be placed in a semiprivate room. Educational objective:The priority nursing action for a client who has made a recent suicide attempt is to ensure the client's safety. The best approach is to provide one-on-one contact and constant observation.

"You do not have privileges for leaving the unit. I cannot give you a pass."

A client on the locked unit of an inpatient psychiatric hospital says to a nurse on the evening shift, "During the day they let me out to go to the gift shop. You're my favorite nurse; I know you'll be a good sport and give me a pass." What is the best response by the nurse? Explanation Manipulative behaviors, such as attempts at staff splitting, are common in clients with borderline and antisocial personality disorders, substance abuse problems, somatic symptom disorder, and bipolar disorder (during the manic phase). The manipulative behavior is aimed at gaining control/power over a person/situation or for material gratification. Clients manipulate by flattery or by pitting staff members against each other. They may "tell" on a staff member or act in a way to give the impression of sincerity and caring. Nursing interventions for manipulative behaviors include: Setting limits that are realistic, nonpunitive, and enforceable Using a nonthreatening, matter-of-fact tone when discussing limits and consequences of unacceptable behaviors Enforcing all unit, hospital, or center rules (Option 4) Ensuring consistency from all staff members in enforcing set limits (Option 1) Telling the client the gift shop is closed does not address the client's manipulative behavior. (Option 2) Believing the client's statement is not appropriate as it will only reinforce the client's manipulative behavior. (Option 3) Asking the client the reason for going to the gift shop ignores the fact that the client is trying to break the rules. Educational objective:Clients who want to gain power or control over a situation or desire material gratification may use manipulative behaviors (eg, staff splitting). Nursing interventions include setting behavioral limits; using a neutral, matter-of-fact tone when discussing rules and consequences of unacceptable behavior; and ensuring consistency from staff members in enforcing limits.

Thiamine, IV

A client presents to the emergency department with alcohol intoxication. Assessment shows nystagmus, ataxia, and confusion. The client's breath smells of alcohol. Which prescription from the health care provider should the nurse implement first? -Nystagmus is an involuntary rhythmic side-to-side, up and down or circular motion of the eyes that occurs with a variety of conditions. -Ataxia describes poor muscle control that causes clumsy voluntary movements. Explanation Clients with alcoholism can have hypoglycemia. They can also have thiamine (vitamin B1) deficiency related to poor nutrient intake (a healthy diet contains enough thiamine) and alcohol-induced suppression of thiamine absorption. Thiamine deficiency can result in Wernicke encephalopathy (WE). Untreated WE can lead to death or neurologic morbidity (Korsakoff psychosis). In the setting of alcoholism, administered glucose is oxidized by using all the existing thiamine in the body; this can worsen thiamine deficiency, which in turn can precipitate the development of WE in a previously unaffected individual. Because the signs of alcohol intoxication and WE are similar, all intoxicated clients should be given IV thiamine before or with IV glucose (Options 2 and 4). (Option 1) A blood draw for liver functions tests to rule out alcoholic hepatitis is important but not a priority. (Option 3) Clients with alcoholism usually have additional nutritional deficiencies (eg, folic acid, magnesium). Magnesium and multiple vitamins should also be given to these clients. However, thiamine is the essential vitamin to administer before or with IV glucose in a client with suspected alcoholism. Educational objective:IV thiamine is given before or with IV glucose to a client with alcohol intoxication to prevent Wernicke encephalopathy. Clients with alcoholism often have thiamine deficiency.

Denial and projection

A client recently admitted to an inpatient unit for treatment of alcoholism says to the nurse, "I only came here to get away from my nagging spouse. Sometimes I think my spouse is the one who should be here. I can stop drinking any time I want." The nurse recognizes that the client is exhibiting which of the following defense mechanisms? Explanation Defense mechanisms are strategies or responses, usually unconscious, used by individuals to distance themselves from a full awareness of unpleasant thoughts, internal conflicts, and external stresses. Defense mechanisms protect the ego from threatening thoughts and anxiety. Denial is the refusal to accept the reality of threatening situations, or painful thoughts, feelings, or events. It is the most frequent defense mechanism used by clients with alcoholism; the client may deny that drinking is a significant problem and that any issues or problems can be handled alone. This client is also using projection by saying that the spouse should be hospitalized; projection involves placing one's own thoughts, feelings, or impulses onto someone else. (Options 2, 3, and 4) Rationalization, regression, displacement, sublimation, and reaction formation are not the primary defense mechanisms used by the client. This client displays no symptoms of depression. Educational objective:The most common defense mechanism used by persons with alcoholism is denial, the refusal to accept the reality of threatening situations, or painful thoughts, feelings, or events. Projection involves placing one's own thoughts, feelings, or impulses onto someone else.

"What are the voices saying to you?"

A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to the nurse, "The voices are bad today...they are so angry with me." Which of the following is the best response by the nurse? The priority nursing action is to explore the content of the hallucinations. This client may be experiencing command auditory hallucinations that could lead to self-directed or other-directed injury and harm. After the content of the hallucinations has been explored, implementing an intervention may be necessary to reduce the potential for violence. Hallucinations are false sensory perceptions that have no external stimuli. They can occur in any of the 5 senses. Auditory hallucinations are the most common, followed by visual, tactile (touch), olfactory (smell), and gustatory (taste). Additional ways to deal with hallucinations include the following: Telling the client that you know they are real to the client but that you do not hear the voices (or see the vision, feel the sensation) Not arguing with or challenging the client about the hallucinations Directing the client to a reality-oriented topic of conversation or activity (Option 1) An antianxiety medication may be needed if the voices are causing this client to become increasingly distressed. Assessment is needed before choosing this option. (Option 2) This choice dismisses this client's concerns about the nature of the voices. (Option 3) Telling the voices to "go away" (voice dismissal) is a technique that some clients find effective in management of hallucinations. It is not the priority nursing action in this client. Educational objective:It is important for the nurse to initially explore the content of a client's hallucinations to assess the risk for harm and/or injury and determine appropriate interventions. The nurse can tell the client that the nurse knows the voices are real to the client but are not heard by the nurse. The client with hallucinations should be directed to reality-oriented activities rather than to further discussion of the content of the hallucinations.

Remain in the room with the client

A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking, hyperventilating, and having heart palpitations. What is the priority nursing action? Explanation This client is experiencing the symptoms of a panic attack and should not be left alone. The priority nursing action is to stay with the client to ensure the client's safety and offer support. Additional nursing actions while the client is experiencing panic symptoms include: Maintaining a calm, matter-of-fact approach Speaking calmly and using simple, clear words and phrases when providing information on emergency department procedures Placing the client in a room with as few stimuli as possible Administering an anti-anxiety medication such as a benzodiazepine (per health care provider prescription) Having the client take slow, deep breaths if hyperventilation is a problem (Option 1) Deep breathing exercises can relieve hyperventilation, but the priority is to remain with the client to ensure safety. (Option 2) Discussing the reasons for the panic attack is not appropriate while the client is still symptomatic. Once the client has calmed down, the nurse can discuss reasons for the attacks, evaluate stressors in the client's life, and assist the client in developing prevention strategies. (Option 3) A private room is appropriate; however, just telling a client to relax is not helpful. Educational objective:The priority nursing action for the client experiencing symptoms of a panic attack is for the nurse to stay with the client in a calm environment, ensure the client's safety, and offer support.

Our social worker can discuss long-term care options with you.

A client with Alzheimer disease is admitted to the hospital for a urinary tract infection. The daughter says to the nurse, "I really want to take my mother home and continue care there. However, lately, my mother has become agitated and restless at night. I'm awake most of the night, feel exhausted, and do not know what to do." What is the best response by the nurse? Explanation This caregiver is experiencing high levels of stress and exhaustion related to caring for the client; without help, the caregiver could easily experience burnout. A social worker can provide information on resources and services for assistance and support; these include adult day programs, in-home assistance, visiting nurse services, and home-delivered meals. The social worker can also provide the names of agencies that seek the support of others in similar situations (eg, local chapter of the Alzheimer's Association). (Option 1) Keeping a client with Alzheimer disease awake during the day is a behavioral strategy that may reduce the risk of sundowning (increased confusion and agitation in the evenings). However, this response does not address the caregiver's stress and exhaustion. (Option 3) Antipsychotic medications are used cautiously in elderly clients with dementia due to the high risk of a cardiovascular event. This response does not provide an effective approach to the caregiver's increasing levels of stress. (Option 4) Institutional care may be the best option for this client. However, giving an opinion or telling the caregiver what the appropriate action "should" be is a non-therapeutic response. Educational objective:Caregivers of clients with Alzheimer disease and other types of dementia often experience burnout due to stress and exhaustion. They need information on community resources that can provide assistance with client care.

"It is your responsibility to sign in when you return from a pass."

A client with a diagnosis of antisocial personality disorder was given a 2-hour pass to leave the hospital. The client returned to the unit 15 minutes past curfew and did not sign in. The next day, this behavior is brought up in a group meeting. The client says, "It's all the nurse's fault. The nurse was right there and did not remind me to sign in." What is the best response by the nurse? Explanation Clients with antisocial personality disorder often disregard the rules, have a history of irresponsible behavior, and blame others for their behavior. They avoid responsibility for their own behavior and the consequences of their actions using numerous excuses and justifications. Nursing interventions include setting firm limits and making clients with antisocial personality disorder aware of the rules and acceptable behaviors. The nurse should require the client to take responsibility for his/her own behavior and the consequences of not following the rules and regulations of the unit. (Option 1) This is a non-therapeutic response; by apologizing to the client, the nurse is implying that it was the nurse's responsibility to remind the client to sign in. (Option 2) This is a non-therapeutic response as the nurse is on the defensive and not focusing on the client. (Option 4) This is a non-therapeutic response; it is confrontational and assumes the reasoning behind the client's behavior. The response also requires a yes or no answer, which does not facilitate communication. Educational objective:Clients with antisocial personality disorder often disregard the rules, have a history of irresponsible behavior, and blame others for their behavior. Nursing interventions include setting firm limits and making clients aware of the rules and acceptable behaviors.

Risk for deficient fluid volume

A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the priority nursing diagnosis? Explanation A diagnosis of schizophrenia with catatonia can be made if the clinical features meet the criteria for a diagnosis of schizophrenia and include at least 2 of the following additional features: Immobility—the client remains in a fixed stupor or position for long periods - Refuses to move about or engage in activities of daily living - May have brief spurts of excitement or hyperactivity Remaining mute Bizarre postures—the client holds the body rigidly in one position Extreme negativism—the client resists instructions or attempts to be moved Waxy flexibility—the client's limbs stay in the same position in which they are placed by another person Staring Stereotyped movements, prominent mannerisms, or grimacing Clients with catatonic schizophrenia are unable to meet their basic needs for adequate fluid and food intake and are at high risk for dehydration and malnutrition. The priority nursing action is to anticipate the client's needs, and to ensure that the client is well hydrated and has adequate nourishment. Some clients will need total care. (Option 1) Impaired social interaction is also an appropriate nursing diagnosis in a client with catatonic schizophrenia. However, it is not a priority, especially during the early phases of the disease. (Option 2) The client's mutism makes the diagnosis of impaired verbal communication appropriate, and the nurse should gently encourage this client to talk without undue expectations or pressure. This is not the priority nursing diagnosis. (Option 4) If this client is in a bizarre or fixed posture, there may be a risk for decreased circulation and pressure ulcers. The nurse needs to encourage ambulation and/or provide range-of-motion exercises. Educational objective: Clients with catatonic schizophrenia are unable to meet their own needs for fluids, food, movement, and elimination and need assistance in performing basic activities of daily living. However, a priority diagnosis is deficient fluid volume.

"Your spouse is very ill and ECT might be the best treatment at this time. What are your concerns about ECT?"

A client with a history of major depressive disorder with psychotic features was rescued before jumping off a dam. The client is pacing, picking at the arms, and repeatedly mumbling, "I have to die. You cannot stop me." When the health care provider recommends electroconvulsive therapy (ECT) as the initial treatment, the client's spouse says to the nurse, "I can't allow such a cruel treatment. Why can't they just give my spouse medication?" Which is the best response by the nurse? Explanation Due to the severity of this client's clinical presentation, ECT would be the appropriate initial treatment. The client's depression has psychotic features and the suicide attempt used a highly lethal method. The client continues to be highly suicidal as evidenced by behavior and thought content. ECT can be highly effective in helping severe depression, when clients pose a severe threat to themselves and it is not safe to wait until medications take effect. ECT is also used in clients who have not responded to medication or cannot tolerate side effects. During ECT, the client is treated with pulses of electrical energy through electrodes applied to the scalp; the electrical stimulus is sufficient to cause a brief convulsion. General anesthesia and a skeletal muscle relaxant are administered to minimize the motor seizure and prevent musculoskeletal injury. The client feels nothing from the procedure, but confusion and memory loss are common side effects. The usual course of acute therapy is 6-12 ECT treatments performed 2-3 times a week. Response to ECT can be dramatic and life-saving. Maintenance therapy (treatment at 1- to 8-week intervals) can continue on a long-term basis to help prevent relapses. Medication therapy is often given in combination with ECT and is associated with improved outcomes. The best response to a client or family member who expresses doubts about ECT is to ask about their concerns. Responses such as, "Tell me about your concerns," or "What do you understand about ECT?" allow the nurse to assess their knowledge and implement educational interventions to address any misinformation or knowledge gaps. (Option 1) This response does not address the spouse's concerns. (Option 2) Although this statement may be true, it does not address the spouse's concerns. It is not the best response. (Option 3) This is a non-therapeutic statement; it does not address the spouse's concerns and suggests a threatening tone. Educational objective:ECT is an effective treatment for major depression with psychotic features or for a client who is highly suicidal. ECT is used when it is unsafe to wait for medication treatment to become effective. It is also used in clients who do not respond to or cannot tolerate psychotropic medications.

This is unacceptable. I had my whole day planned out.

A client with a history of obsessive-compulsive personality disorder (OCPD) is seeking treatment for a gastrointestinal disorder and is scheduled for a colonoscopy at 10:00 AM. Due to a computer glitch, the procedure is postponed to 3:00 PM. Which response would be characteristic of an individual with OCPD? Evaluation Individuals with obsessive-compulsive personality disorder are typically self-willed and obstinate, punctual, pay attention to rules and regulations, and need to control both internal and external experiences. These traits are very extreme and result in rigidity and inflexibility. In this scenario, a change has been made in the client's schedule for the day and is outside of the client's control. This could cause significant distress and impaired functioning so that the client feels emotionally paralyzed. (Option 1) This response is characteristic of a client with narcissistic personality disorder, who may behave in grandiose, demanding, and entitled ways and needs to have his/her own way. (Option 2) This response could be attributed to a client with dependent personality disorder, who tends to be passive and submissive and wants to please others. (Option 4) This response would be more characteristic of an individual with paranoid personality disorder, who may feel slighted or is overly sensitive. Educational objective:An individual with obsessive-compulsive personality disorder is typically rigid and inflexible and has a need to control both internal and external experiences. A change in a schedule that is outside of the client's control could cause significant distress.

Assign different staff members to care for the client each day

A client with borderline personality disorder says to the nurse, "You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you." What is the priority action for the client's nursing care plan? Explanation Individuals with borderline personality disorder (BPD) live in fear of rejection and abandonment. To avoid abandonment, they use manipulation and control, often unconsciously, to prevent a person from leaving. The manipulative behavior may be of a positive nature, such as the use of flattery, or a negative nature, such as distancing from the other person. An individual with BPD may also engage in self harm or suicidal behaviors in an attempt to gain attention from the other person and keep that person from leaving. For this client, the nursing care plan must include the assignment of different staff members. This will help diminish the client's dependence on a particular individual and help the client learn to relate to more than one person. (Option 2) Continuing to assign the client's stated preferred nurse will reinforce the manipulative behavior and the need to cling to one person. (Option 3) Simply telling the client about staff competency will not facilitate behavior change. The client is engaging in this behavior as a protection against abandonment. (Option 4) It is important to reinforce unit rules and the consequences of inappropriate behaviors. However, this is not the best action to address the client's attempt to manipulate the staff. Educational objective:Clients with borderline personality disorder, in an attempt to prevent abandonment and control their environment, may flatter and cling to one staff member while making derogatory remarks about others. The best nursing action is to rotate staff members assigned to care for the client.

2. Distract and redirect the client by asking for help folding napkins for the following day's meals 5. Use direct eye contact and say to the client, "I can see that you are upset; this is a safe place"

A client with moderate Alzheimer disease becomes agitated during mealtime and throws a plate of food on the floor. Which of the following responses by the nurse are appropriate? Select all that apply. Explanation Clients with Alzheimer disease (AD) often exhibit behavioral problems (eg, agitation, resisting care) due to cognitive decline. Behavioral management techniques include: Acknowledgement of the client's emotions, which reduces feelings of being isolated and misunderstood (Option 5) Reassurance that the client will be kept safe from harm Distraction (eg, photographs, music, television) to divert the client's attention Redirection to simple tasks (eg, folding towels/napkins, stacking plates) (Option 2) (Option 1) Antipsychotic medications (eg, haloperidol, risperidone, olanzapine) are associated with increased mortality when used for agitation in clients with dementia. These medications should be used after all other measures have failed. (Option 3) Threatening to call the health care provider disrupts the nurse-client relationship and may worsen the client's agitation and behavioral problems. (Option 4) Offering activities that may have precipitated the behavior will likely worsen the agitation. The nurse should assess the client to determine the cause of the agitation (eg, pain, fear, fatigue) and address it. A new meal can be offered after the client is calm. In addition, the nurse should promote autonomy for as long as possible and should not feed clients who are still able to feed themselves (eg, client with moderate AD). Educational objective:Behavioral management for agitated clients with Alzheimer disease includes acknowledging client feelings, reassuring safety, distracting, and redirecting.

"I have signed up to be a dog walker when I normally would watch television."

A client with obesity reports several failed attempts at weight loss. Which client statement best indicates that the client is ready and motivated for successful weight loss? Explanation Successful behavior modification (eg, diet and exercise for effective weight loss) requires client readiness and motivation to change, which can be assessed using the Stages of Change Model. With the appropriate support (eg, listening, not pressuring the client), clients can move from one stage to the next: Precontemplation: The client does not believe a problem exists, although others may point it out (eg, encouraging healthy eating) (Option 4). Contemplation: The client recognizes a change is needed but is undecided whether it would be possible or worthwhile (Option 2). Preparation: The client has decided to change, explores emotions related to the decision, and begins establishing goals (eg, fitting into a dress) (Option 3). Action: The client has firmly committed to changing, has developed a plan (eg, dietary modifications, exercise plans), and actively takes steps toward new behavior (eg, choosing activity over television) (Option 1). Maintenance: The client continues to uphold the new behavior and focuses on preventing relapse. Termination: The client has achieved the desired change. This stage may be theoretical, as relapse to former behaviors is always possible. Educational objective:Successful behavior modification requires client readiness and motivation to change, as evidenced by the client developing and acting on a plan. Clients often do not initially see the need for change, but with the appropriate support they begin contemplating change, preparing to change (eg, goal setting), and then actively changing.

Give a reminder that the client has been cleaning the bathroom for 1½ hours and it is time to take a break

A client with obsessive-compulsive disorder (OCD) has been cleaning a bathroom for most of the morning. When the roommate demands that the client leave the bathroom so that the roommate can shower, the client becomes angry and says, "You can't make me leave, everything is still dirty." What is the best nursing action? Explanation Clients with OCD engage in rituals and behaviors that help reduce the anxiety or stress rooted in their obsessions (recurrent thoughts, impulses, or images that cause notable distress). If the ritual is interrupted, the client will experience increased anxiety. A client with compulsive behavior often does not realize the amount of time or how many times the same activity has been performed. By providing reflective feedback about the client's behavior, the nurse is acknowledging the behavior in a nonjudgmental manner. The nurse should also help the client become involved in other activities and problem-solving skills. (Option 1) Engaging other staff members to remove the client from the bathroom is confrontational and will increase the client's and roommate's anxiety; this approach is not necessary or therapeutic. (Option 3) Pointing out that the bathroom is clean does not change the client's obsessive thoughts. Saying that the client's behavior is unreasonable conveys a message of disapproval and would increase the client's anxiety. (Option 4) Telling the roommate to use a different bathroom allows the client to continue the ritualistic behavior, is non-therapeutic, reinforces the behavior, and avoids the issue. Educational objective:Clients with OCD engage in rituals and activities that help reduce the anxiety associated with unacceptable thoughts, images, and impulses. Therapeutic approaches to a client with OCD include pointing out the amount of time the client has spent performing an activity and redirecting the client to another activity.

Provide earphones and a DVD player and have the client sing along with the music

A client with schizophrenia has been hospitalized for a week and placed on an antipsychotic medication. The client tells the nurse of hearing multiple voices all day long arguing about whether the client is a good or bad person. The client says, "Everyone tells me that the voices are not real, but they are driving me crazy." What is the best action by the nurse? Explanation Auditory hallucinations are the most common type of hallucination and are typically experienced by individuals with a diagnosis of schizophrenia, bipolar disorder, or other psychotic illness. Antipsychotic medication therapy is the first-line treatment of hallucinations and other psychotic symptoms. However, most psychotropic drugs may take some time to be completely effective and may not eliminate hallucinatory episodes entirely. Clients should be encouraged to develop alternate methods for coping with the hallucinations. One approach is increasing the amount of external auditory stimulation in the environment. Individuals with auditory hallucinations have reported that increasing the amount of external sound (eg, watching TV or listening to music through headphones) makes it easier to ignore internal sounds from the hallucinations. Other methods of managing auditory hallucinations include voice dismissal (telling the voices to go away) and cognitive behavioral therapy (assists clients in learning new ways to think about and deal with their symptoms). (Option 1) Reading a book may provide some distraction, but it does not increase external auditory stimulation. (Option 3) The medication may not start to work for another 2 weeks and may not eliminate these symptoms entirely. (Option 4) The client is hearing voices all day long; ignoring them is not as effective as an activity that distracts the client from the hallucinations. Educational objective:Although antipsychotic medication is the first-line treatment for diminishing or eliminating psychotic symptoms, such as hallucinations, clients need other strategies for coping with distressing symptoms. Increasing external auditory stimulation often helps distract the client from the internal voices and focus on reality.

Loose associations

A client with schizophrenia says to the nurse, "The world turns as the world turns on a ball at the beach. But all the world's a stagecoach and I took the bus home." The nurse recognizes this statement as an example of which of the following? Explanation Disturbance in logical form of thought is characteristic and one of the positive symptoms of schizophrenia. The client will often have trouble concentrating and maintaining a train of thought. Thought disturbances are often accompanied by a high level of functional impairment, and the client may also be agitated and behave aggressively. Types of impaired thought processes seen in individuals with schizophrenia include the following: Neologisms - made-up words or phrases usually of a bizarre nature; the words have meaning to the client only. Example: "I would like to have a phjinox." Concrete thinking - literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase, "The grass is always greener on the other side," would be interpreted to mean that the grass somewhere else is literally greener (Option 1). Loose associations - rapid shifting from one idea to another, with little or no connection to logic or rationality (Option 2) Echolalia - repetition of words, usually uttered by someone else Tangentiality - going from one topic to the next without getting to the point of the original idea or topic (Option 3) Word salad - a mix of words and/or phrases having no meaning except to the client. Example: "Here what comes table, sky, apple." (Option 4) Clang associations - rhyming words in a meaningless, illogical manner. Example: "The pike likes to hike and Mike fed the bike near the tyke." Perseveration - repeating the same words or phrases in response to different questions Educational objective:Disturbance in thought process (form of thought) is one of the positive symptoms of schizophrenia. The nurse needs to be able to recognize and identify the various types of thought disturbances experienced by clients with schizophrenia. These include loose associations, neologisms, word salad, echolalia, tangentiality, clang association, and perseveration.

The client's boss has asked the client to represent the company at an upcoming convention

A client with social anxiety disorder is receiving treatment at the local community mental health center. Which situation most likely caused the client to seek therapy? Explanation Social anxiety disorder (SAD) is characterized by an excessive and persistent fear of social or performance situations in which the client is exposed to strangers and the possibility of scrutiny by others. Examples of such social interactions include meeting unfamiliar people, being observed eating or drinking in public, and giving a speech. The client may fear criticism, embarrassment, humiliation, and rejection from unfamiliar people in unfamiliar social situations and will exhibit physical symptoms of anxiety such as sweating, trembling, palpitations, diarrhea, and blushing. Although all these situations could provoke some degree of anxiety in a client with SAD, having to represent the company at a convention with hundreds of strangers is most likely what brought this client to the community mental health center. Clients with SAD often have anticipatory anxiety and worry for days or weeks before a feared event. They may recognize that their fear is exaggerated and will seek assistance and counseling. (Option 1) The prospect of a new neighborhood may cause the client some anxiety; however, in this situation, the client has some control over exposure to new neighbors. The client can control this fear by limiting encounters or avoiding the neighbors altogether. (Option 3) Seeing a new HCP may cause some degree of discomfort in a client with SAD; however, as a one-on-one encounter, it is not like to cause severe anxiety or panic. (Option 4) In this situation, the client will be around familiar and possibly unfamiliar people. If necessary, the client can create a comfort zone by limiting contact with unfamiliar people. Educational objective:Clients with social anxiety disorder have an excessive, persistent fear of social or performance situations involving strangers and the possibility of criticism, embarrassment, humiliation, and rejection. The fear of the situation(s) causes severe anxiety and avoidance.

I will help you get ready; then we can walk to the dining room together.

A client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting. The nurse enters the room to remind the client that breakfast will be served in the dining room in 20 minutes. The client says, "I'm not hungry and I don't feel like doing anything." What is the best response by the nurse? Explanation Reduced appetite and low energy level are common clinical findings in major depressive disorder. The lethargy accompanying the depressed mood makes it difficult for a client with this diagnosis to even get up and out of bed. Personal hygiene and grooming are neglected, and there is no desire to interact with others. The client needs direction and structure in performing activities of daily living (ADLs); waiting for the client to feel more energetic and initiate activity and interaction on one's own is not helpful. Assisting the client with ADLs helps convey a sense of caring, provides an opportunity for interaction with the nurse, and helps raise the client's self esteem. (Option 2) This action reinforces the client's desire to stay in the room and is not therapeutic. (Option 3) This response is non-therapeutic; the client needs assistance with ADLs. (Option 4) Clients with depression often do feel better after even minimal exercise and activity. However, this response does not give the client direction or structure. Educational objective:Clients with low energy, lethargy, or fatigue associated with major depressive disorder need structure and direction in performing basic ADLs, including personal hygiene and grooming. The nurse needs to provide assistance to the client in completing ADLs and in initiating social interaction with others.

Remain silent and allow the client to leave

A newly admitted client with schizophrenia has been exhibiting severe social withdrawal, odd mannerisms, and regressive behavior. The client is sitting alone in the room when the nurse enters, says "good morning," and proceeds to sit down next to the client. Without responding, the client stands up and starts to leave. Which of the following actions is best for the nurse to take? Explanation Clients with schizophrenia often become anxious when around other individuals and will seek to be alone to relieve anxiety. Impaired social and interpersonal functioning (eg, social withdrawal, poor social interaction skills) are common negative symptoms of schizophrenia. These are more difficult to treat than the positive symptoms (eg, hallucinations, delusions) and contribute to a poor quality of life. Nursing interventions directed at improving the social interaction skills of a client with schizophrenia include the following: Making brief, frequent contacts Accepting the client unconditionally by minimizing expectations and demands Assessing the client's readiness for longer contacts with the nurse and/or other staff and clients Being with or close by the client during group activities Offering positive reinforcement when the client interacts with others (Option 1) Asking where this client is going is nontherapeutic as it requires an explanation of the client's actions. (Option 2) Following this client out the door could increase the client's anxiety. (Option 3) Directing this client to come back to the room is placing a demand that may be unrealistic and does not help develop a sense of trust. Educational objective:Social isolation and impaired social interaction are common negative symptoms of schizophrenia. The client will seek to be alone to relieve anxiety associated with being around others. The nurse needs to be accepting of the client's behavior and continue attempts at brief contact until the client is comfortable.

Continue with a detailed interview and physical examination

A nurse is admitting a child and observes multiple irregular bruises. Which action should the nurse take next? Explanation A nurse who suspects child abuse should conduct a detailed interview and physical examination to identify potential indicators of abuse (Option 2). In addition to obvious injuries, abused children may show extremes in behavior, including being overly shy, fearful, or even unusually affectionate. Parents should remain present during the admission process and the nurse should observe parent-child interactions for signs of abusive behavior (eg, refusal to comfort, blaming, belittling) (Option 1). Abusive parents may be hostile or uncooperative with the health care team. The nurse should also assess for inconsistencies between the parents' report and the actual findings. (Option 3) The nurse should report findings that indicate abuse to the charge nurse, social worker, and health care provider only after conducting a full history and physical examination. (Option 4) The nurse should not make promises of secrecy to the child or family if abuse is revealed. The child or family should be told that the nurse is required by law to report all abuse. Educational objective:If child abuse is suspected, the nurse should obtain a detailed history, perform a physical examination, and report signs of abuse. Parent-child interaction should be examined closely, and any inconsistencies between a parent's report and the actual findings should be documented.

"Very soon everything will be much better."

A nurse is caring for a client who was admitted following a suicide attempt. Which client statement is most concerning? Explanation A client who has attempted suicide is at risk for repeated attempts and death by suicide. After beginning treatment (eg, antidepressant therapy), clients are at even higher risk because they begin to have more energy, allowing them to follow through with suicide plans. The nurse should assess the client's verbal and nonverbal cues and recognize that a sudden positive outlook is the most concerning sign that the client may have determined a plan for suicide and is at peace with it (Option 4). The nurse should directly ask the client about a suicide plan. (Options 1 and 2) Hopelessness (belief that a situation is intolerable, inescapable, or unending) and anger are expected reactions to an unsuccessful suicide attempt. The nurse should encourage clients to share feelings to build rapport, support the client, and decrease feelings of isolation during an acute suicidal episode. (Option 3) It is common for clients with depression and recent suicidal ideation to have either insomnia or excessive sleepiness. If sleep disturbances continue after the therapeutic effect of prescribed antidepressants should have occurred, the medication regimen may require adjustment. Educational objective:Clients who have attempted suicide are at risk for repeated attempts and death by suicide. The nurse should assess the client's behaviors and comments, and if a client has a sudden positive outlook, the nurse should directly ask about a suicide plan.

A client who is experiencing a fever and diarrhea 2 days after the health care provider increased the sertraline dose

A nurse working at a mental health clinic is reviewing four messages from clients requesting a same-day appointment. Which client does the nurse prioritize to call back first? Explanation Serotonin can be increased by the addition or high doses of serotonergic medication, or by some herbal medications (eg, St. John's wort), placing clients at risk for serotonin syndrome. Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia). The nurse should call this client back to investigate the symptoms further. (Option 1) Panic attacks can be frightening but typically last less than 10 minutes. A panic attack following a stressful event does not pose an immediate risk; the request for a refill of alprazolam (benzodiazepine for acute anxiety relief) can wait. (Option 3) Phenelzine is a monoamine oxidase inhibitor that has multiple food interactions (eg, foods containing tyramine), which can cause hypertensive crisis. This client needs further education to prevent this condition, but is asymptomatic and not in immediate danger. (Option 4) Stimulants (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are commonly used for attention-deficit hyperactivity disorder (in both children and adults) and are commonly associated with insomnia, irritability, diminished appetite, weight loss, and headaches. Educational objective:Serotonin can be increased by the addition or high doses of serotonergic medication, or by some herbal medications (eg, St. John's wort), placing clients at risk for serotonin syndrome.

Risk for suicide

A young adult with obesity comes to the free clinic for a 2-week post-antibiotic follow-up visit for a superficial abdominal skin abscess. The client has a history of major depressive disorder and was hospitalized twice in the past 6 months for attempted suicide. The client now reports feeling "emotionally upset, alone, and at the end of my rope," due to difficulty finding a job and inability to qualify for medical insurance. The client is currently prescribed fluoxetine but has not been able to follow up with the prescribing health care provider (HCP). What is the priority nursing diagnosis (ND) at this time? Explanation Suicide is the second leading cause of death in people age 15-24. The risk for suicide is increased in individuals with psychiatric disorders, such as depression, and in those who have attempted suicide within the past 2 years. Based on the client's history and statements, the HCP must perform a suicide assessment and take action (ie, psychiatry referral) to provide for the client's safety. This is imperative as the client is prescribed the antidepressant fluoxetine (Prozac) and has had no follow-up with the prescribing HCP. Risk for suicide related to depression is the priority ND. (Option 1) Hopelessness is the belief that a situation or problem is intolerable, inescapable, or unending, and the individual is unable to find a solution. Hopelessness related to inability to find a job, social isolation, lack of medical insurance, and feeling at the "end of my rope" is an appropriate ND for this client, but it is not the priority ND at this time. (Option 2) Ineffective coping is the inability to manage stressors and problems effectively. Depression can affect a client's cognitive ability (eg, poor concentration, lack of judgment) and ability to cope with feelings of despair. Ineffective coping related to inadequate support network, limited socioeconomic resources, and impaired cognitive ability is an appropriate ND for this client, but it is not the priority ND at this time. (Option 3) Risk for infection related to inadequate primary defenses secondary to impaired skin integrity is an appropriate ND for this client, but it is not the priority ND at this time. Educational objective: Risk for suicide related to depression is a priority ND for a client with previous suicide attempts.

Place a chain lock on the door above or below the client's eye level

After a client with Alzheimer disease is found wandering in the middle of the street at 3:00 AM and returned by police, the community health nurse teaches family members about measures to keep the client safe at home. What is the most important strategy for the nurse to include in the instruction? Explanation Individuals with dementia may wander and become lost during any stage of the disease. The most effective strategy to prevent wandering is to make modifications to secure the environment. These include: Placing locks above or below eye level on doors that lead to the outside. Clients with Alzheimer disease (AD) lose their peripheral vision; they cannot see objects unless they are directly in front of them or they purposely move their heads (Option 3). Adding a motion sensor or alarm that goes off when someone tries to exit Placing a large stop sign on door exits Disguising a door with a curtain or wall hanging Using childproof doorknob covers Placing a black mat or black strip by an exit. The client may perceive this as an impassable black hole due to changes in depth perception. (Option 1) Clients with AD should not be left alone; however, it is impossible for any caregiver to watch another person every minute of the day. Clients with AD can walk out of their homes while family members are sleeping. (Option 2) Notifying neighbors can be helpful if the client leaves the residence but will not prevent wandering. (Option 4) Safe return or identification bracelets are important, but they will not prevent wandering. A bracelet should be placed on the dominant hand to minimize the chance of removal. Educational objective:The most effective strategy to prevent clients with dementia from wandering is to make modifications to secure their environment. These include installing locks above or below eye level on doors, hiding exits with wall hangings or curtains, placing a black mat in front of exits, and using doorknob covers, motion detectors, and alarms.

"I don't see you that way; you are making progress toward a healthy weight."

After a daily weigh-in, a client with anorexia nervosa realizes a 2-lb weight gain. The client says to the nurse in a distressed voice, "This is terrible. I'm so fat." What is the best response by the nurse? Explanation A nursing diagnosis associated with anorexia nervosa is disturbed body image/low self esteem. There is often a large disparity between actual weight and the client's perceived weight. Clients with anorexia nervosa think of themselves as overweight and fat. The nursing care plan should include helping the client develop a realistic perception of weight and body image. The nurse can confront the client about the misinterpretation of body weight by presenting reality without challenging the client's illogical thinking. The client's weight should be discussed in the context of overall health. The nurse also needs to be aware of his/her own reaction to the client's behaviors and statement. It is not uncommon for caregivers and care providers to feel frustrated or even angry when caring for a client with an eating disorder. The nurse must maintain a neutral attitude and approach, avoiding arguing or disagreeing with the client's statements. (Option 1) This response is judgmental, reinforces the idea of "thinness," and does not help the client develop a more realistic body image. (Option 3) Establishing a goal weight is part of the nursing care plan for the client with anorexia nervosa; clients are usually not discharged from inpatient treatment until goal weight is achieved. However, this response does not address the client's misperception of body weight. (Option 4) This response dismisses the client's concern and does not present the reality of the situation. Educational objective:Clients with anorexia nervosa have disturbed body image and see themselves as being fat or overweight even when they are severely underweight or even at a normal body weight. The nurse can help the client develop a more realistic self image by presenting the situation realistically and discussing weight in terms of the client's health.

Providing one-on-one supervision

An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation, confusion, and disorientation to time and place. What is the most important nursing action? Explanation This client is experiencing impairment in cognitive and psychomotor functioning and most likely has delirium brought on by the urinary tract infection. This is not an uncommon occurrence in elderly clients. The client's most immediate needs are safety and prevention of physical injury. Initially, the client should be placed in a room near the nurses' station with one-on-one supervision and frequent reorientation to time, place, and situation. As the condition improves, the client will continue to require frequent observation. (Option 1) It is important for this client to be well hydrated; this can best be accomplished through IV fluids and electrolyte replacement but not by encouraging the client to increase fluid intake. (Option 2) Clients who are agitated often try to get out of bed, even if it means climbing over the side rails. Keeping the bed elevated and side rails raised increases the risk of a fall or other injury as the client attempts to leave the bed. (Option 4) A dark room could worsen the client's confusion, agitation, and disorientation. Lighting helps maintain orientation to the environment; the client's room should be well lit during the day, and dim nightlights should be used at night. Educational objective:Safety is a high priority for clients with delirium. Disorientation, confusion, agitation, and difficulty interpreting reality all increase the risk for physical injury. Close observation, including one-on-one supervision, is essential to ensure client safety.

"I can stay and sit with you if you would like."

An elderly client at the end of life is visited by family members. One begins to cry and asks the nurse, "Will you please stay for a few minutes?" The nurse has other clients to care for as well. Which statement by the nurse is the most helpful? Explanation During the end-of-life process the client's family members may be frightened, sad, confused, or concerned, and may ask staff questions about belief systems or the death process. Sometimes clients or family members simply want the nurse to sit with them and provide reassurance that their loved ones are worthy of time and attention. The most therapeutic response by the nurse is to sit with the client and/or family for at least a few minutes. (Option 1) Telling family members that a nurse is busy is not a helpful response. They may feel guilty about asking for the nurse's time and attention. If needed, the nurse can ask coworkers to help with other assigned clients. (Option 2) Although calling clergy members may be appropriate, it may take several hours for them to arrive. This is not the most helpful response. (Option 4) Family members who ask the nurse to stay for a few minutes may have questions or need emotional support. In such cases, it is not helpful for the nurse to decline. Educational objective:During the end-of-life process, the client and family members typically go through several emotional stages, each requiring therapeutic communication techniques by the nurse. The nurse can help the client and family by providing a few minutes of time and attention. The nurse should validate the family's needs by providing emotional support.

"It's time to get back to bed now."

An elderly client with dementia frequently exhibits sundowning behavior while living in a community-based residential facility. When the nurse finds the client wandering at night, which of the following statements is most appropriate? Explanation Sundowning refers to the increased confusion experienced by an individual with dementia; it occurs at night, when lighting is inadequate, or when the client is excessively fatigued. Wandering is a common associated behavior. A client with mild-to-moderate dementia may need frequent reality reorientation to promote appropriate behaviors. However, with advanced dementia, reality orientation may not be effective and might cause the client to feel anxious, leading to inappropriate behaviors and aggression. In this situation, validation therapy is more appropriate and involves recognizing and exploring the client's feelings and concerns but not reinforcing or arguing with any incorrect perceptions. (Option 1) This statement calls attention to the client's memory and cognitive issues but does not provide any useful information for reorientation. In addition, this type of statement may reinforce anxieties and fears in a client who is already feeling insecure and scared about the cognitive changes, leading to anger and possible aggression. (Option 3) This option provides little reorientation information. (Option 4) This statement has a paternalistic tone and seems to penalize the client. This type of statement may cause the client to get angry, leading to escalating negative behaviors. Educational objective:Appropriate communication techniques to assist a client with dementia while avoiding anxiety and other negative behaviors include reorientation in the earlier stage of dementia and validation in the later stage of dementia.

Clients are attempting to regulate self-esteem

Clients with narcissistic personality disorder often behave in grandiose and entitled ways, believe that they are perfect, and rely on constant reinforcement and admiration from people perceived as ideal. What is the best explanation for these clinical characteristics? Narcissistic personality disorder (NPD) is characterized by a recurrent pattern of grandiosity, the need for admiration, and lack of empathy. Clients with NPD are hypersensitive to criticism and may project superiority, arrogance, and independence to hide their true sense of self. Narcissistic traits often derive from a distorted view of oneself that develops from childhood neglect or criticism. Clients with NPD often experience extremely fragile levels of self-esteem. These individuals develop characteristics of self-importance to protect themselves, to regulate self-esteem, and to avoid feelings of fear or abandonment. Characteristics of NPD are rigid and pervasive because clients often lack the understanding that these traits are problematic (Option 1). (Option 2) Clients with NPD are more likely to experience grandiosity (ie, exaggerated belief of self-importance), not hallucinations. (Option 3) Clients with NPD may feel threatened or criticized if others do not meet their emotional demands. However, this is not the best explanation of the clinical characteristics associated with NPD. (Option 4) Panic attacks are characteristic of anxiety disorder, not NPD. Educational objective:Narcissistic personality disorder (NPD) is characterized by recurrent patterns of grandiosity, an exaggerated belief of self-importance, and an inability to empathize with others. Clients with NPD develop characteristics of self-importance to regulate their fragile self-esteem.

1.Assist the client to identify circumstances that increase anxiety 2.Provide positive feedback when the client attends a group activity 3.Refrain from judgmental comments about counting magazines 4.Remove the magazines from the commons room 5. Teach the client how to use the technique of thought stopping

The nurse plans care for a client newly admitted with obsessive-compulsive disorder who is repeatedly counting magazines in the commons room. Which of the following should the nurse include in the initial plan of care? Select all that apply. Explanation Obsessive-compulsive disorder is characterized by obsessions (ie, persistent and intrusive thoughts, impulses, or images) and compulsions (ie, ritualistic, repetitive behaviors performed to reduce anxiety or prevent an adverse event). Clients are aware that such behavior is irrational, but performing the actions provides relief, which compels them to continue. Initially, nursing care includes: Assisting the client to identify circumstances that increase anxiety (Option 1) Offering positive feedback when the client engages in nonritualistic behavior (eg, group activities, board games) (Option 2) Remaining nonjudgmental and empathetic and using reflective communication (Option 3) Cognitive-behavioral therapy (eg, thought stopping) (Option 5) (Option 4) Suddenly denying the client the ability to perform the ritualistic activity can cause panic-level anxiety. Instead, the nurse should gradually limit the time allotted to the ritualistic behavior, once the client is equipped with new coping mechanisms. Educational objective:Obsessive-compulsive disorder is characterized by persistent, intrusive thoughts (obsessions) and behaviors performed ritualistically and repetitively to try to reduce anxiety (compulsions). Nursing care includes assisting the client to identify anxiety-producing situations, allowing time for the ritualistic behavior (initially), remaining nonjudgmental, offering positive feedback, and providing cognitive-behavioral therapy.

Have you had any thoughts of hurting yourself?

The home health aide reports to the nurse care manager that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, "With my spouse dead, there's no reason for me to go on." What is the best priority response by the nurse? Explanation Giving away possessions and making statements such as, "There is no reason for me to go on," are indications of suicidal ideation. The most important nursing action is to perform a suicide risk assessment to determine interventions to ensure the client's safety. Determining if the client has had thoughts of self harm is a priority. The nurse can ask the client direct questions such as, "Do you feel like hurting yourself?" or "Are you thinking about killing yourself?" or "Do you want to die?" During the assessment, it is important for the nurse to create a sense of trust and compassion and engage the client in a nonjudgmental manner. Additional questions that are part of a suicide risk assessment include the following: Have you thought about how you would kill yourself? Do you have a plan to kill yourself? If you were to kill yourself, how would you do it? If the client has a suicide plan, the nurse needs to ask about the details. The risk of a client completing suicide increases when the client has planned for a specific time and place, has chosen a highly lethal method (eg, firearm, hanging), and has chosen circumstances in which there would be little or no chance of interruption. (Option 1) It is important to assess the client's social support system, but it is not the priority assessment. (Option 3) This is not the priority assessment; it is more important to determine if the client is thinking about suicide or has a plan. (Option 4) This is a leading question and implies what the answer should be. Educational objective:A suicide risk assessment is the priority nursing action for a client who expresses thoughts about "not wanting to go on" or "wishing for death" or engages in potential suicidal indicators such as giving away possessions. Asking the client directly about thoughts of hurting or killing oneself is a therapeutic approach and an essential component of the risk assessment.

1."How would you describe your child's usual behavior at home?" 3."What forms of discipline do you use with your child?" 4."When you are stressed, what coping mechanisms do you use?" 5."Who watches your child when you are at work?"

The home health nurse assesses a child and suspects that the child is being abused. Which of the following questions are appropriate for the nurse to ask the caregiver? Select all that apply. Explanation When the nurse suspects that a child may be the victim of child abuse, the parent or caregiver should be questioned, and all possibilities (eg, alternate caregivers) should be explored to find the source of the abuse. If possible, the interview should be done without the child present. The nurse should remain supportive and empathetic and convey a nonjudgmental, nonthreatening attitude, avoiding words such as "abuse" and "violence." Open-ended questions are less threatening and provide more detailed responses. Information to gather includes: Caregiver's perspective on the child's behavior (Option 1) Methods of discipline used with the child (Option 3) Routine caregivers for the child Caregiver stress, coping, and support systems (Option 4) Person or persons who care for the child when regular caregivers are away (Option 5) (Option 2) Use of the words "excessive" and "suspicious" to describe the child's bruising conveys judgment. This may cause the caregiver to become defensive and limit the nurse's ability to establish trust and find the source of the abuse. Educational objective:When child abuse is suspected, the nurse should convey empathy and support when questioning a caregiver while maintaining a nonjudgmental, nonthreatening attitude. Open-ended questions are less threatening and provide more detailed responses.

The client has an intense need to control the environment

The nurse is caring for a client with paranoid personality disorder. When the nurse directs the client to go to the dining room for dinner, the client says, "And eat that poisonous food? You better not make me go anywhere near that room." Which statement best explains the client's behavior? Explanation Individuals with paranoid personality disorder have a pervasive distrust and suspicion of others; they believe that people's motives are malicious and assume that others are out to exploit, harm, or deceive them. These thoughts permeate every aspect of their lives and interfere with their relationships. Individuals with paranoid personality disorder are usually difficult to get along with as they may express their suspicion and hostility by arguing, complaining, making sarcastic comments, or being stubborn. Because these clients do not trust others, they have a strong need to be self-sufficient and maintain a high degree of control over their environment. (Option 1) This statement best describes an individual with antisocial personality disorder. (Option 3) Clients with paranoid personality disorder do not have psychotic symptoms. (Option 4) Clients with paranoid personality disorder will usually not be able to control their anger when confronted with a real or imagined threat. Educational objective:Paranoid personality disorder is characterized by distrust and suspicion of others. Because these clients do not trust other people, they have an intense need to control them and their environment.

1.Client breaks eye contact when discussing caregiver 2.Client has lost 8 lb (3.63 kg) in the previous 4 weeks 4.Client's eyeglasses have been visibly broken for 1 month 5.Client's prescription medication is expired

The home health nurse visits a 75-year-old client with mild Alzheimer dementia who recently moved in with a caregiver. Which observations would cause the nurse to suspect neglect? Select all that apply. Elder abuse or neglect occurs when caregivers intentionally or unintentionally fail to meet the older adult client's physical, emotional, or social needs. Approximately 1 in 10 older adult clients are victims of physical, psychological, or sexual abuse by a caregiver. Commonly neglected necessities include water, food, medication, hygiene, and clothing. The client's living conditions may be unsafe or have inadequate access to public utilities. Objective findings consistent with abuse or neglect include: Dehydration, malnutrition, and weight loss (Option 2) Poor hygiene, soiled bedding or clothing, and pressure ulcers Missing/broken assistive devices (eg, eyeglasses); medications withheld or expired (Options 4 and 5) Clients who have experienced abuse or neglect may find the situation difficult to discuss and display apprehension, restlessness, withdrawal, poor eye contact, shame, and despair (Option 1). The client may also deny or minimize the extent of the abuse out of fear or embarrassment. (Option 3) Clothing that is out of style is not indicative of neglect. However, soiled clothing or clothing unsuitable for the weather (eg, no jacket on a cold day) does indicate possible neglect. Educational objective:Manifestations of abuse or neglect in an older adult may include development of pressure ulcers, poor hygiene, dehydration, malnutrition, weight loss, soiled bedding/clothing, missing/broken assistive devices, and missing or expired medications.

"Be sure to take your valproic acid prior to the procedure."

The new nurse is providing teaching to a client scheduled for electroconvulsive therapy (ECT). What information given by the new nurse would cause the charge nurse to intervene? Explanation Electroconvulsive therapy (ECT) induces a generalized seizure by passing an electrical current through electrodes applied to the scalp. Although the exact mechanism is unknown, 15-20-second seizures are proven effective in treating mood disorders (eg, major depression, bipolar disorder) and schizophrenia. Client teaching includes: NPO status is required for 6-8 hours prior to treatment except for sips of water with medications (Option 4). Anesthesia (eg, methohexital, propofol) and a muscle relaxant (eg, succinylcholine) will be administered; clients are unconscious and feel no pain during the procedure. Driving is not permitted during the course of ECT treatment (Option 2). Temporary memory loss and confusion in the immediate recovery period are common side effects of ECT (Option 3). Post-treatment nursing care includes monitoring vital signs, ensuring a patent airway, assessing mental status, and providing frequent reorientation during periods of postictal confusion. (Option 1) Valproic acid (Depakote) is an anticonvulsant that is also prescribed for bipolar disorder; therefore, it would prevent the therapeutic effect of ECT. Any prescribed anticonvulsants should be discontinued prior to ECT. Educational objective:Electroconvulsive therapy (ECT) uses an electrical current applied to the scalp to induce a generalized seizure in an anesthetized client. Prior to the procedure, the client should be NPO and not take anticonvulsant medications. Temporary confusion and memory loss are common after the procedure. Clients should be instructed not to drive during the course of ECT treatment.

Likes to be the center of attention, exaggerated emotional expression, little tolerance for frustration

The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors? Explanation The nurse should recognize the following characteristics associated with histrionic personality disorder: Self-dramatizing, exaggerated or shallow emotional expression Attention-seeking, needs to be the center of attention Overly friendly and seductive, attempts to keep others engaged Demands immediate gratification and has little tolerance for frustration An individual with histrionic personality disorder displays these behaviors and characteristics persistently. The signs and symptoms are maladaptive and have a negative impact on the client's social, interpersonal, and occupational life. (Option 1) Clients with dependent personality disorder fear separation and tend to be indecisive and unable to take the initiative. They are often preoccupied with the thought of being left to fend for themselves and want others to assume responsibility for all major decision making. (Option 3) Clients with schizoid personality disorder exhibit social detachment and an inability to express emotion. They do not enjoy close relationships and prefer to be aloof and isolated. (Option 4) Clients with antisocial personality disorder have a pattern of disregard for and violation of the rights of others. They manipulate others for personal gain and lack empathy. Educational objective:Histrionic personality disorder is characterized by persistent attention-seeking behavior and exaggerated emotionality. The client with this disorder demands immediate gratification and has little tolerance for frustration.

Tell me more about your thoughts and feelings regarding the situation.

The nurse cares for a client who just had surgical excision and biopsy of a tumor. The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider. The client asks the nurse, "Am I going to die?" Which statement by the nurse is appropriate? Explanation Clients with life-limiting diagnoses often experience anxiety, frustration, and the phases of grief. The nurse must assess the client's knowledge and feelings regarding the illness. Use of therapeutic communication (eg, active listening, reflection, focusing) allows the nurse to determine client needs and strengthens the nurse-client relationship, which is instrumental in helping the client cope with difficult information (Option 2). The health care provider (HCP) should inform the client of biopsy results so that the prognosis and plan of treatment can be discussed. Although a cancer diagnosis may be difficult for the client to receive, a complete, factual discussion of the diagnosis can help the client feel more in control. (Option 1) Indicating knowledge of the client's feelings and changing the subject weaken the nurse-client relationship by making the nurse seem uncomfortable with the situation, minimizing the client's feelings, and disregarding client concerns. (Option 3) The HCP should be involved in informing the client about the biopsy results. It is best that both the HCP and nurse be present to address all questions and concerns the client may have. (Option 4) An automatic response is a nontherapeutic communication technique that deflects the client's feelings, thereby weakening the nurse-client relationship. The nurse should encourage the client to share their thoughts. Educational objective:Clients with life-limiting diagnoses experience anxiety, frustration, and grief as they cope. The nurse should use therapeutic communication (eg, active listening, reflection, focusing) to determine the client's understanding and strengthen the nurse-client relationship before discussing difficult news (eg, new cancer diagnosis).

Assist the client in reflecting on triggers of disordered eating Maintain strict record of protein and calorie intake Remain with the client for the duration of each meal Weigh the client each morning prior to any oral intake

The nurse is admitting a client with malnutrition related to anorexia nervosa. Which of the following actions are appropriate to include in the care of this client? Select all that apply. Explanation Anorexia nervosa is a psychogenic eating disorder with potentially fatal physiological implications. Clients commonly become extremely underweight and protein-energy malnourished. Clients admitted for anorexia nervosa are typically in a crisis state, and the priority is restoring physiological integrity through appropriate weight gain and nutritional intake. Nursing care includes: Assisting the client in reflecting on triggers for dysfunctional eating and fears and feelings related to gaining weight (Option 2) Maintaining strict documentation of dietary protein and calorie intake to ensure healthy weight gain (Option 3) Remaining with the client during and 1 hour following meals to ensure intake and prevent purging behaviors (Option 4) Establishing a weekly weight-gain goal (typically 2-3 lb/wk [0.91-1.36 kg/wk]) Weighing the client at the same time each morning (after voiding and before any oral intake) and wearing the same clothing to assess efficacy of nutritional support (Option 5) Limiting physical activity initially and gradually increasing as oral intake improves Not focusing on food initially, but encouraging participation in meal planning as the client nears target weight (Option 1) Clients admitted with anorexia nervosa should not continue to exercise, because this would cause further energy deficit and worsen malnutrition and end-organ damage (eg, renal failure). Educational objective: Clients admitted with anorexia nervosa must increase caloric intake and stop exercising to promote weight gain. The nurse should record consumed calories, weigh the client daily, remain with the client during and for 1 hour following meals, and encourage discussion about dysfunctional eating triggers.

During 1-2 hours after each meal

The nurse is caring for a client with bulimia nervosa. Which is the most important time for the nurse to monitor the client's behavior? Explanation The eating behavior of a client with bulimia nervosa typically consists of binge eating followed by an inappropriate behavior to prevent weight gain, such as self-induced vomiting, exercise, and/or excessive use of laxatives. Although it is important to provide one-on-one supervision to a client with bulimia during every meal, it is most important to monitor the client's activities for 1-2 hours after each meal to prevent self-induced vomiting (Option 2). Clients with bulimia nervosa will often go to extreme lengths to engage in purging activity, especially at the beginning of a treatment program, as a way of gaining control. After mealtime, it may be necessary to restrict clients to the dayroom or a specified area with no bathroom privileges for a set period. Clients will also need to be monitored at all times for engaging in excessive exercise. (Option 3) Clients need to be monitored during every meal, not just during the evening meal. (Option 4) Secretive bingeing and purging during the night or before bedtime are not uncommon for a client with bulimia nervosa. However, in a structured inpatient environment, the client would not have access to excessive amounts of food. Educational objective:Clients with bulimia nervosa should be supervised during every meal. However, it is most important to monitor the postprandial activity of these clients to prevent self-induced vomiting as a way to prevent weight gain.

I know you are frightened, but I do not see a man in your room.

The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. The client says in a trembling voice, "There's a bad man standing over there in the corner of my room." What is the best response by the nurse? Explanation An important step toward self-management of hallucinations is for the client to recognize that the hallucinations are not real. When a client is experiencing hallucinations, the nurse needs to reinforce reality and acknowledge how the client may be feeling. The nurse can point out his/her own perceptions without denying the client's experience. It is nontherapeutic to argue with or challenge the client about the hallucination, saying, for example, "How could a man get into your room? This is a locked hospital unit." Examples of additional therapeutic responses to a client who is experiencing hallucinations include the following: "I don't see anything, but I understand that what you are seeing may be very upsetting to you." "I understand that you are worried about the voices you are hearing. They are a part of your disease and not real." "I know the voices seem real to you and may be scary. I do not hear the voices." (Option 2) This response reinforces the hallucination and does not present reality to the client. (Option 3) This response ignores what the client is experiencing and does nothing to reduce the client's feeling of discomfort. (Option 4) This response provides an explanation for the client's experience but does not acknowledge the client's feelings or reinforce reality. Educational objective:The most therapeutic response to a client experiencing hallucinations presents reality and acknowledges how the client may be feeling. This approach promotes self-management by helping the client recognize that the hallucinations are not real.

"How are you feeling about your baby?"

The nurse is caring for a new mother whose infant has been diagnosed with Down syndrome. The client says to the nurse, "I'm so worried. My husband is so devastated that he won't even look at the baby." What is the best response by the nurse? Explanation Learning that their newborn has a genetic disorder (eg, Down syndrome) is an overwhelming experience for most parents. They may initially react with shock, disbelief, and/or denial. Once they accept the diagnosis, parents may be filled with uncertainty and doubt and experience an array of emotions, including guilt, depression, and anger about the presumed loss of their perfect child. When helping the family cope with the crisis, the nurse needs to keep the lines of communication open and offer support. The nurse should use open-ended therapeutic communication techniques that encourage the family members to verbalize what they are feeling or experiencing (Option 2). (Option 1) This is a true statement; supportive counseling is usually beneficial to new parents of children with disabilities. The nurse can refer clients to family support groups or even make the initial phone call for them. However, the nurse should first encourage the parents to express how they are feeling. (Option 3) This is not the best response. The nurse has a role and responsibility to offer support to clients experiencing a crisis. (Option 4) This is accusatory and nontherapeutic. The nurse should avoid asking "why" questions when attempting to gain more information. Educational objective:Parents of newborns diagnosed with Down syndrome or other developmental disabilities may experience shock or disbelief along with a wide array of emotions. Nurses should be supportive by using therapeutic communication techniques that encourage the family to talk about what they are experiencing and/or feeling.

Client has clear future plans involving personal goals and family milestones

The nurse is conducting a follow-up interview with a client who is being treated for depression and suicidal ideation. What factor best indicates that the client is not currently at risk for suicide? Explanation When caring for a client with depressive symptoms (eg, suicidal ideation [SI]), the nurse should continuously screen for self-harm thoughts, behaviors, and intent. During the client interview, both risk and protective factors of suicide should be explored. Protective factors include the following: Support systems and availability of help during a crisis (eg, counselor, family) Contact with efficient mental health care services Being married and/or having children Problem-solving skills and planning of long-term goals (Option 2) (Option 1) Clients experiencing depressive symptoms are often prescribed antidepressant medications (eg, selective serotonin reuptake inhibitors [SSRIs]) that cause increased energy levels, placing clients at risk to carry out a suicide plan. (Option 3) Giving away prized possessions (eg, favorite books, picture frames) is an indicator of an impending suicide attempt. (Option 4) Tricyclic antidepressant medications (eg, amitriptyline, nortriptyline) can be fatal in an overdose. Although the nurse may interpret the client's report of having lost the prescription as an attempt to be compliant, the nurse must also be aware that the client may be stockpiling medication for a suicide attempt. Educational objective:During the interview with a client experiencing suicidal ideation, both risk and protective factors of suicide should be explored. Protective factors include support systems and availability of help during a crisis; contact with efficient mental health care services; being married and/or having children; as well as problem-solving skills and planning of long-term goals.

"These decisions are challenging. Tell me your spouse's beliefs about end-of-life."

The nurse is speaking with the spouse of a client following a family discussion with the health care provider about the client's terminal condition and eligibility for hospice care. The spouse states, "I don't think I can make this decision right now. What would you do?" How should the nurse respond? Explanation End-of-life decisions (eg, hospice, code status) often overwhelm clients and medical decision-makers due to the magnitude of the choices and feelings of guilt that may accompany decisions. Clients and their families may lean on hospital staff to guide these decisions. These moral and ethical dilemmas require the nurse to have strong therapeutic communication skills. When discussing decisions related to client care, the nurse should facilitate exploration of the client's emotions, values, and beliefs, rather than offer personal opinions. Nurses can promote self-exploration by using open-ended questions and guiding phrases (Option 3). (Option 1) Providing information is an appropriate response when that is what the client is seeking. However, there is no indication that the spouse seeking advice requires additional information, and this response does not promote further communication. (Option 2) The nurse's opinion and personal biases can influence clients/family members and may even push them toward decisions incongruent with their values and beliefs. Giving advice is not therapeutic and does not promote open communication. (Option 4) It is within the nurse's scope to discuss moral and ethical decisions with clients. Deferring these conversations to another professional (eg, chaplain) instead of talking with the individual inhibits the therapeutic relationship and does not support client self-exploration. Educational objective: When discussing ethical decisions related to client care, it is important for the nurse to use open-ended questions and guiding phrases to facilitate exploration of clients'/family members' emotions, values, and beliefs regarding the topic. Nurses should avoid giving advice and influencing individuals' decisions.

List of everyday items containing hidden alcohol

The nurse provides teaching for a client newly prescribed disulfiram for alcohol abstinence. Which information is the priority for the nurse to include? Explanation Disulfiram (Antabuse) is a form of aversion therapy that promotes abstinence from alcohol. If the client consumes alcohol while taking disulfiram, unpleasant side effects (eg, headache, intense nausea/vomiting, flushed skin, sweating, dyspnea, confusion, tachycardia, hypotension) can occur. If large amounts are consumed, the reaction can be fatal. Disulfiram therapy does not cure alcoholism; the client should continue seeing a therapist (Options 1 and 2). Due to the hazards of treatment, clients are carefully selected for disulfiram therapy, and informed consent is often required. It is a priority for the nurse to educate the client about the hazards of drinking alcohol and about sources of hidden alcohol (Option 3). Teaching includes: Avoid hidden alcohol in:liquid cold and cough medicationsaftershave lotions, colognes, and mouthwashesfoods such as sauces, vinegars, and flavor extracts Abstain from alcohol for 2 weeks after the last dose as the disulfiram reaction could still occur Wear a bracelet alerting others of being on disulfiram therapy (Option 4) Educational objective:Disulfiram is a medication that promotes abstinence from alcohol by causing uncomfortable, potentially fatal reactions when alcohol is consumed. Clients must avoid sources of hidden alcohol (eg, liquid cough medicine, aftershave, mouthwash). Effects of the drug can last 2 weeks after the last dose.

"What do you see at the door?"

The nurse speaks with a client diagnosed with schizophrenia who begins to look away toward the door and grimace. Which response by the nurse is most therapeutic at this time? The goal of therapeutic communication with clients diagnosed with schizophrenia is building trust, self-awareness, reality testing, and self-confidence. The nurse should be aware of client cues that indicate hallucinations (distraction, mumbling, watching a vacant area of the room). This client might be having a visual hallucination, as evidenced by being distracted and grimacing. The nurse must assess for hallucinations that might direct or cause the client to be unsafe or aggressive (eg, suicidal or homicidal themes). It is most therapeutic to ask the client what is being sensed (eg, seen, heard, smelled, tasted, felt). Once the specifics of the hallucination are known, the nurse can help the client properly cope with the situation (Option 3). (Option 1) Suggesting the client look at the nurse while speaking does not help the client now. Later, when the nurse knows exactly what the client is seeing, it might be appropriate to redirect the client to the conversation as a way to ignore the hallucination. (Option 2) Ending the conversation would not be therapeutic as it does not allow the nurse to help the client during the hallucination. (Option 4) Focusing on the nurse's perception of the client not trusting the nurse is not therapeutic because it addresses the nurse's, not the client's, needs. Educational objective:Communication with a client experiencing a hallucination should first focus on the nature of the hallucination so that the nurse can assess for suicidal or homicidal themes.

Your spouse should be seen in the clinic today.

The spouse of a client with borderline personality disorder calls the clinic and reports that the client has self-inflicted superficial lacerations to the arm. The spouse tells the nurse, "When I prepare to travel for work, my spouse does this to stop me from leaving. It's not an attempt of serious harm." What is the best response by the nurse? Explanation Borderline personality disorder (BPD) is a mental health disorder characterized by unstable relationships and self-image, mood lability, excessive anger, fear of abandonment, impulsive behaviors, and recurrent suicidal behavior. Clients with BPD may use these behaviors to gain a response from others when there is a real or perceived risk of abandonment from a significant other. Clients with BPD may demonstrate years of benign suicidal threats and gestures before committing suicide. Predicting a client's risk for completing suicide is difficult due to the impulsive nature of the behavior. Any potentially suicidal behavior must be taken seriously, and this client should be evaluated immediately to assess for suicidal intent (Option 4). (Options 1 and 3) The priority is for the client to be evaluated at the clinic due to the diagnosis and risk for suicide. The spouse's response to the client's behavior can be discussed later. (Option 2) The nurse should address the client's needs first. It would be appropriate to provide support for family members after the client's needs have been met. Educational objective:Borderline personality disorder is characterized by unstable relationships and self-image, mood lability, excessive anger, fear of abandonment, impulsive behaviors, and recurrent suicidal behavior. Suicidal threats and behaviors must be taken seriously and evaluated immediately for suicidal intent. Psychosocial Integrity